MICROBIOLOGY

MEDICAL COURSE AND STEP 1 REVIEW

FIRST EDITION

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Michael Christensen & Rhett Thomson
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 TABLE OF CONTENTS
MICROBIOLOGY FUNDAMENTALS................................................................................6
Section 1 - Bacterial Structures...................................................................................................................................................... 6
Section 2 - Virulence.................................................................................................................................................................... 10
Section 3 - Bacterial Genetics...................................................................................................................................................... 20
Section 4 - Prion Diseases............................................................................................................................................................ 27
Section 5 - Introduction to Fungi................................................................................................................................................. 29
Section 6 - Viral Structures.......................................................................................................................................................... 32
Section 7 - Viral Genetics............................................................................................................................................................ 35
Section 8 - Viral Genomes and Replication................................................................................................................................. 38

BACTERIA.............................................................................................................................41
Section 1 - Clostridium tetani...................................................................................................................................................... 42
Section 2 - Clostridium botulinum............................................................................................................................................... 44
Section 3 - Clostridium difficile .................................................................................................................................................. 46
Section 4 - Clostridium perfringens............................................................................................................................................. 48
Section 5 - Bacillus anthracis...................................................................................................................................................... 50
Section 6 - Bacillus cereus........................................................................................................................................................... 52
Section 7 - Listeria monocytogenes............................................................................................................................................. 54
Section 8 - Corynebacterium diphtheriae ................................................................................................................................... 56
Section 9 - Viridans streptococci................................................................................................................................................. 58
Section 10 - Streptococcus pneumoniae...................................................................................................................................... 60
Section 11 - Streptococcus pyogenes........................................................................................................................................... 62
Section 12 - Streptococcus agalactiae......................................................................................................................................... 66
Section 13 - Streptococcus gallolyticus....................................................................................................................................... 68
Section 14 - Enterococci.............................................................................................................................................................. 70
Section 15 - Staphylococcus aureus............................................................................................................................................. 72
Section 16 - Staphylococcus epidermidis.................................................................................................................................... 74
Section 17 - Staphylococcus saprophyticus................................................................................................................................. 76
Section 18 - Nocardia ................................................................................................................................................................. 78
Section 19 - Actinomyces israelii................................................................................................................................................. 80
Section 20 - Neisseria overview ................................................................................................................................................. 82
Section 21 - Neisseria meningitidis............................................................................................................................................. 84
Section 22 - Neisseria gonorrhoeae ........................................................................................................................................... 86
Section 23 - Moraxella catarrhalis ............................................................................................................................................. 88
Section 24 - Haemophilus influenzae........................................................................................................................................... 90
Section 25 - Bordetella pertussis................................................................................................................................................. 94
Section 26 - Pasteurella multocida, Brucella spp., and Francisella tularensis........................................................................... 96
Section 27 - Salmonella spp......................................................................................................................................................... 98
Section 28 - Salmonella typhi.................................................................................................................................................... 100
Section 29 - Shigella.................................................................................................................................................................. 102
Section 30 - E. coli..................................................................................................................................................................... 104
Section 31 - Klebsiella............................................................................................................................................................... 108
Section 32 - Proteus mirabilis................................................................................................................................................... 110
Section 33 - Pseudomonas aeruginosa...................................................................................................................................... 112
Section 34 - Yersinia pestis and enterocolitica.......................................................................................................................... 116
Section 35 - Enterobacter, Citrobacter, & Serratia marcescens................................................................................................ 118
Section 36 - Bartonella henselae .............................................................................................................................................. 120
Section 37 - Legionella pneumophila........................................................................................................................................ 122
Section 38 - Campylobacter jejuni............................................................................................................................................ 124
Section 39 - Vibrio cholerae & Vibrio vulnificus....................................................................................................................... 126
Section 40 - Helicobacter pylori................................................................................................................................................ 128
Section 41 - Mycobacterium tuberculosis.................................................................................................................................. 130
Section 42 - Mycobacterium leprae .......................................................................................................................................... 134
Section 43 - Mycobacterium avium-intracellulare, Scrofulaceum, and Marinum.................................................................... 138
Section 44 - Borrelia burgdorferi.............................................................................................................................................. 140
Section 45 - Leptospira interrogans........................................................................................................................................... 142
Section 46 - Treponema pallidum.............................................................................................................................................. 144
Section 47 - Chlamydia trachomatis, Chlamydophila pneumoniae, and Chlamydophila psittaci............................................ 148
Section 48 - Coxiella burnetii.................................................................................................................................................... 150
Section 49 - Gardnerella vaginalis............................................................................................................................................ 152
Section 50 - Mycoplasma pneumoniae...................................................................................................................................... 154
Section 51 - Rickettsia prowazekii, Rickettsia rickettsii, and Rickettsia typhi.......................................................................... 156
Section 52 - Ehrlichia & Anaplasma......................................................................................................................................... 158
Section 53 - Miscellaneous Organisms...................................................................................................................................... 160

FUNGI...................................................................................................................................165
Section 1 - Histoplasma capsulatum.......................................................................................................................................... 166
Section 2 - Blastomyces dermatitidis......................................................................................................................................... 168
Section 3 - Coccidioides immitis................................................................................................................................................ 172
Section 4 - Paracoccidioides brasiliensis.................................................................................................................................. 174
Section 5 - Microsporum, Trichophyton, and Epidermophyton................................................................................................. 176
Section 6 - Malassezia furfur..................................................................................................................................................... 180
Section 7 - Sporothrix schenckii................................................................................................................................................ 182
Section 8 - Candida albicans..................................................................................................................................................... 184
Section 9 - Aspergillus fumigatus.............................................................................................................................................. 188
Section 10 - Cryptococcus neoformans..................................................................................................................................... 190
Section 11 - Mucor & Rhizopus spp.......................................................................................................................................... 192
Section 12 - Pneumocystis jirovecii........................................................................................................................................... 194

PARASITES.........................................................................................................................197
Section 1 - Giardia lamblia....................................................................................................................................................... 198
Section 2 - Entamoeba histolytica............................................................................................................................................. 200
Section 3 - Cryptosporidium...................................................................................................................................................... 202
Section 4 - Toxoplasma gondii................................................................................................................................................... 204
Section 5 - Naegleria fowleri..................................................................................................................................................... 206
Section 6 - Trypanosoma brucei, gambiense, and rhodesiense................................................................................................. 208
Section 7 - Malaria.................................................................................................................................................................... 210
Section 8 - Babesia.................................................................................................................................................................... 214
Section 9 - Trypanosoma cruzi.................................................................................................................................................. 216
Section 10 - Leishmania donovani............................................................................................................................................. 218
Section 11 - Trichomonas vaginalis........................................................................................................................................... 220
Section 12 - Enterobius vermicularis (pinworm)...................................................................................................................... 222
Section 13 - Ascaris lumbricoides (giant roundworm).............................................................................................................. 224
Section 14 - Strongyloides stercoralis (threadworm)................................................................................................................ 226
Section 15 - Ancylostoma duodenale and Necator americanus (hookworms).......................................................................... 228
Section 16 - Trichinella spiralis................................................................................................................................................. 230
Section 17 - Trichuris trichiura (whipworm)............................................................................................................................ 232
Section 18 - Toxocara canis....................................................................................................................................................... 234
Section 19 - Onchocerca volvulus............................................................................................................................................. 236
Section 20 - Loa loa and Wuchereria bancrofti......................................................................................................................... 238
Section 21 - Taenia solium......................................................................................................................................................... 240
Section 22 - Diphyllobothrium latum........................................................................................................................................ 243
Section 23 - Echinococcus granulosus...................................................................................................................................... 244
Section 24 - Schistosoma haematobium, mansoni, and japanicom........................................................................................... 246
Section 25 - Clonorchis sinensis................................................................................................................................................ 248
Section 26 - Sarcoptes scabiei................................................................................................................................................... 250
Section 27 - Pediculus corporis, pubis and capitis.................................................................................................................... 252

VIRUSES..............................................................................................................................254
Section 1 - Herpes simplex virus-1 (HSV-1) and herpes simplex virus-2 (HSV-2).................................................................. 255
Section 2 - Varicella-zoster virus (VZV)................................................................................................................................... 260
Section 3 - Epstein-Barr Virus (EBV)....................................................................................................................................... 262
Section 4 - Cytomegalovirus (CMV)......................................................................................................................................... 264
Section 5 - Roseola (HHV-6 and HHV-7).................................................................................................................................. 266
Section 6 - Kaposi sarcoma (HHV-8)........................................................................................................................................ 268
Section 7 - Hepatitis B Virus (HBV)......................................................................................................................................... 270
Section 8 - Smallpox, Cowpox, and Molluscum contagiosum.................................................................................................. 274
Section 9 - Human papillomavirus............................................................................................................................................ 276
Section 10 - Adenovirus............................................................................................................................................................. 280
Section 11 - JC Virus and BK Virus........................................................................................................................................... 282
Section 12 - Parvovirus B19...................................................................................................................................................... 284
Section 13 - Coronavirus and SARS.......................................................................................................................................... 286
Section 14 - Human immunodeficiency virus (HIV)................................................................................................................. 288
Section 15 - Human T-lymphotropic virus (HTLV)................................................................................................................... 292
Section 16 - Hepatitis C Virus (HCV)....................................................................................................................................... 294
Section 17 - Yellow fever .......................................................................................................................................................... 296
Section 18 - Dengue Fever......................................................................................................................................................... 298
Section 19 - West Nile Virus and St. Louis Encephalitis........................................................................................................... 300
Section 20 - Zika Virus.............................................................................................................................................................. 302
Section 21 - Rubella................................................................................................................................................................... 304
Section 22 - Eastern, Western, and Venezuelan equine encephalitis viruses; Chikungunya virus............................................ 306
Section 23 - California Encephalitis.......................................................................................................................................... 308
Section 24 - Rift Valley Fever and Crimean-Congo Hemorrhagic Fever Virus........................................................................ 310
Section 25 - Hantavirus.............................................................................................................................................................. 312
Section 26 - Influenza virus....................................................................................................................................................... 314
Section 27 - Lassa fever encephalitis and Lymphocytic choriomeningitis virus....................................................................... 316
Section 28 - Hepatitis D Virus................................................................................................................................................... 317
Section 29 - Parainfluenza Virus................................................................................................................................................ 320
Section 30 - RSV and hMPV..................................................................................................................................................... 322
Section 31 - Measles.................................................................................................................................................................. 324
Section 32 - Mumps................................................................................................................................................................... 326
Section 33 - Rabies Virus........................................................................................................................................................... 328
Section 34 - Ebola Virus and Marburg Virus............................................................................................................................. 332
Section 35 - Norovirus............................................................................................................................................................... 334
Section 36 - Hepatitis E virus.................................................................................................................................................... 336
Section 37 - Rotavirus and Colorado Tick Fever....................................................................................................................... 338
Section 38 - Poliovirus............................................................................................................................................................... 340
Section 39 - Echovirus............................................................................................................................................................... 342
Section 40 - Rhinovirus............................................................................................................................................................. 344
Section 41 - Coxsackieviruses (A & B)..................................................................................................................................... 346
Section 42 - Hepatitis A Virus.................................................................................................................................................... 348
We would like to extend a special thanks to the following individuasl who have spent many
hours tutoring, guiding and consulting this work, making Physeo Anatomy possible.

Paloma F Cariello, MD, MPH

Assistant Professor
Division of Infectious Diseases
University of Utah School of Medicine
Salt Lake City, UT

Karen Eilbeck, Ph.D.

Professor
Biomedical Informatics
University of Utah

Vicente Planelles, Ph.D.

Professor
Division of Microbiology and Immunology
Department of Pathology
University of Utah School of Medicine
Salt Lake City, UT
 6

MICROBIOLOGY FUNDAMENTALS
Section 1 - Bacterial Structures

I. There are several bacterial structures to be familiar with for board exams. These structures can help bacteria
infect host cells and survive. Some structures are unique to certain groups and can be useful in distinguishing
bacterial organisms.

Structure Description
• Phospholipid bilayer
• Contains lipoteichoic acids in gram-positive bacteria → stimulates host immune response
Cytoplasmic membrane
via TNF-ɑ and IL-1 release
• Contains penicillin-binding proteins (PBPs)
• Peptidoglycan that provides rigidity and structural support to cell
• Thick in gram-positive bacteria (gram staining with crystal violet causes blue appearance)
• Thin in gram-negative bacteria
Cell wall
• Absent in Mycoplasma species which have added sterols to maintain stability (must grow
on Eaton’s agar)
• Contains mycolic acid in Mycobacteria species (must use acid-fast stain)
Flagella • Provides bacterial motility
• Allows bacteria to bind to host cells
Pilus (fimbria)
• Allows bacteria-bacteria binding during conjugation
• Network of polysaccharides
• Slime layer: disorganized and loosely attached to cell wall → creates biofilm on prosthetics
Glycocalyx (capsule or (eg, S. epidermidis)
slime layer) • Capsule: organized and firmly attached to cell wall → protects from phagocytosis (targeted
by many vaccines)
• Note: the capsule of Bacillus anthracis is made of a protein network of poly-ᴅ-glutamate
• Only present in gram-negative organisms (gram counter-staining with safranin causes red
appearance)
Outer membrane • Contains porins → transfer of nutrients
• Contains lipopolysaccharides (LPS: lipid A, core polysaccharide, and O antigen)
• Lipid A stimulates host immune response via TNF and IL-1 release → fever, shock, diarrhea
• Located between outer membrane and cytoplasmic membrane in gram-negative bacteria
Periplasm
• Contains hydrolytic enzymes (eg, β-lactamases)
• Layer formed during dormant state → resists heat, chemicals, dehydration and starvation
→ survival of bacteria
• Only present in gram-positive organisms (Clostridium and Bacillus)
Endospore
• Center containing DNA and dipicolinic acid (DPA) → cytoplasmic membrane (spore core)
→ peptidoglycan wall (spore cortex) → cytoplasmic membrane → keratin-like protein wall
(spore coat) → exosporium (present only in B. anthracis and B. cereus)
Table 5.1.1 - Bacterial structures
 7

Figure 5.1.1 - Gram positive bacterial envelope

Figure 5.1.2 - Gram negative bacterial envelope

 8

Figure 5.1.3 - Envelope of Mycoplasma spp.

Figure 5.1.4 - Envelope of Mycobacteria spp.

Figure 5.1.5 - Acid-fast stain of Mycobacterium Tuberculosis


Figure 5.1.6 - Bacterial endospore
A. Polymerases in bacteria
1. DNA polymerase (replication → more DNA)
a) Mistakes can harm progeny
2. RNA polymerase (transcription → mRNA)
a) Mistakes do not harm progeny
REVIEW QUESTIONS
1. A researcher is attempting to create a novel
staining agent that will only bind to certain
bacterial species. This species cannot form an
endospore, does not contain mycolic acids, and
contains only one phospholipid bilayer. Which of
the following does the organism described most
likely possess?
A. A cytokine inducing structure in outer
membrane
B. A layer that tightly binds to the safranin
counterstain
C. A protein structure allowing for motility
D. A relatively thin layer of peptidoglycan
9
?
• Correct answer: C
• The question stem describes a gram
positive organism
• Contains only one phospholipid
bilayer, so its not gram negative
• Does not contain mycolic acids, so
its not mycobacteria
• Gram positive organisms may contain
flagella
• Choice A is incorrect because this describes
the endotoxin of gram negative bacteria
• Choice B is incorrect because Safranin binds
to the outer membrane found only in gram
negative bacteria
• Choice D is incorrect because thin
peptidoglycan layers are found in
Mycobacteria and gram negative organisms,
not in gram positive bacteria
 10

Section 2 - Virulence

I. Virulence describes the bacteria’s ability to do 3 things:

A. Invade the host
B. Evade immune defenses
C. Inflict disease

Virulence Factor Action Role in Virulence

Pili Adherence Invade the host

IgA protease Adherence Invade the host

Flagella Motility Invade the host

Capsule Prevent phagocytosis Evade immune defenses

M protein Prevent phagocytosis Evade immune defenses

Protein A Prevent phagocytosis Evade immune defenses

Type III secretion system Direct injection of exotoxins into host cell Inflict disease

Endotoxins Triggers host immune response Inflict disease

Exotoxins Secreted from bacteria (activities vary) Inflict disease

Table 5.1.2 - Overview of virulence factors
II. IgA protease IV. Protein A
A. Cleaves IgA antibodies A. Binds to the Fc portion of IgG antibodies → only
the Fab portion of IgG is exposed
B. Allows bacteria to adhere to mucosal surfaces
B. Prevents opsonization and phagocytosis
C. Secreted by multiple bacteria:
C. On the surface of S. aureus
1. S. pneumoniae
2. H. influenzae type b
3. N. meningitidis
4. N. gonorrhoeae

III. M protein
A. Prevents opsonization and phagocytosis
B. Similar to antigens present in the heart →
antibodies that form against the M protein can
attack the heart as well → rheumatic fever
C. Utilized by S. pyogenes (GAS)
 11

Figure 5.1.7 - Protein A mechanism

V. Type III secretion system
A. Protein structure that can insert into host cells
→ injects exotoxins directly into host cell
B. Utilized by several gram negative organisms:
1. Salmonella spp
2. Shigella spp
3. E. coli spp
4. P. aeruginosa
 12

Photo Credit: (left) Pixie [CC BY-SA 3.0 (https://creativecommons.org/license/by-sa/3.0)]; (right) Schraidt O. Lefebre MD, Brunner MJ, Schmied WH, Schmidt A,
Radics J, Mechtier K, Galán JE, Marlovits TC [CC BY 2.5 (https://creativecommons.org/license/by-sa/2.5)]
Figure 5.1.8 - Visual demonstration of Type III secretion systems
VI. Endotoxins VIII. Exotoxins

A. Lipopolysaccharide (LPS) on the surface of gram A. Secreted proteins that inflict disease
negative bacteria B. Utilized by most gram positive and some gram
B. Lipid A is the toxic component of LPS negative bacteria

C. Bacterial cell death → release of lipid A → host C. Source of exotoxin genes:

release of cytokines (TNF-α, IL-1, and IL-6) → 1. Bacterial chromosome
sepsis → severe sepsis → septic shock
2. Plasmids
D. Source of endotoxin genes:
3. Lysogenic bacteriophages following
1. Bacterial chromosome lysogenic conversion (phage DNA can
produce protein products)
VII. Sepsis
A. Sepsis: “Life-threatening organ dysfunction
caused by a dysregulated host response to
infection” (2016 SCCM/ESICM task force)
B. Septic shock: vasopressor required (2016 SCCM/
ESICM task force)
C. Virulence factor triggers host immune response
→ organ dysfunction (hypotension)
1. Gram negative bacteria (lipid A)
2. Gram positive bacteria
3. Fungi

Exotoxin
Diphtheria toxin (C.
diphtheriae)
Exotoxin A (P. aeruginosa)
Shiga toxin (Shigella spp)
Shiga-like toxin (EHEC)
Heat-labile toxin (LT) (ETEC)
Heat-stable toxin (ST) (ETEC)
Cholera toxin (V. cholera)
Edema factor (B. anthracis)
Pertussis toxin (B. pertussis)
Tetanospasmin (C. tetani)
Botulinum toxin (C.
botulinum)
Alpha toxin (C. perfringens)
Streptolysin O (S. pyogenes)
Toxic shock syndrome toxin
(TSST-1) (S. aureus)
Erythrogenic toxin A (S.
pyogenes)
Table 5.1.3 - Bacterial exotoxins
13
Mechanism Result
Inhibit elongation factor 2 (EF-2) Blocked protein synthesis
Inhibit elongation factor 2 (EF-2) Blocked protein synthesis
Remove adenine from rRNA on 60S ribosome (invades
Blocked protein synthesis
GI cells)
Remove adenine from rRNA on 60S ribosome (does not
Blocked protein synthesis
invade GI cells)
Stimulates Gαs subunit → ↑ adenylate cyclase →
Watery diarrhea
↑cAMP → ↑ Cl- & H2O secreted in gut
Guanylate cyclase overactivation → ↑ cGMP → ↓ Cl-
Watery diarrhea
and H2O reabsorption in the gut
Stimulates Gαs subunit → ↑ adenylate cyclase →
Watery diarrhea
↑cAMP → ↑ Cl- & H2O secreted in gut
Mimics adenylate cyclase → ↑ cAMP → cutaneous
Edema around black eschar
edema
Blocks Gαi subunit → ↑ adenylate cyclase → ↑ cAMP →
Persistence of microbe
PMN chemotaxis impaired
Cleaves SNARE proteins → lack of inhibitory
↑ muscular tone
neurotransmitters (GABA, glycine)
Cleaves SNARE proteins → lack of stimulatory
↓ muscular tone
neurotransmitter (ACh)
Lecithinase (a phospholipase) that breaks down cell
Hemolysis and myonecrosis
membrane
A protein that breaks down cell membrane Hemolysis
A superantigen that strongly binds the MHC class II
Toxic shock syndrome (fever,
antigen-presenting cells to the CD4 on TH1 cells →
rash, shock)
perpetual release of IFN-γ, IL-1, IL-2, and TNF-α
A superantigen that strongly binds the MHC class II Toxic shock-like syndrome
antigen-presenting cells to the CD4 on TH1 cells → (fever, rash, shock) & scarlet
perpetual release of IFN-γ, IL-1, IL-2, and TNF-α fever
14

Figure 5.1.9 - Exotoxins that inhibit protein synthesis

Figure 5.1.10 - Exotoxins that increase fluid secretion using adenylate cyclase
 15

Figure 5.1.11 - Exotoxin (heat-stable toxin) that increases fluid secretion through guanylate cyclase

Figure 5.1.12 - Pertussis toxin mechanism

16

Figure 5.1.13 - Mechanism of tetanospasmin

Figure 5.1.14 - Mechanism of botulinum toxin

 17

Figure 5.1.15 - Mechanism of exotoxins that disrupt cell membranes

Figure 5.1.16 - Mechanism of superantigens

18
REVIEW QUESTIONS
1. A bacterial organism produces a virulence factor
that interacts with host antibodies, allowing it to
adhere to host surfaces. Which of the following
statements is consistent with this virulence
factor?
A. It is produced by S. aureus
B. It is secreted from the pathogen
C. It can lead to rheumatic fever
D. It is part of the cell surface
• Correct answer: B
• The virulence factor in question is IgA
protease, based on the following:
• It interacts with host antibodies
• The above interaction allows the
bacteria to adhere to mucosal
surfaces
• IgA protease is secreted
• Choice A is incorrect because S. aureus
produces protein A, not IgA protease
• Choice C is incorrect because this describes
the M protein of S. pyogenes
• Choice D is incorrect because IgA protease is
not part of the cell surface
?
2. An 18-year-old female who has been “feeling
sick” is brought to the emergency department
by her mother. Upon arrival, her temperature is
39.4°C (103.0°F) and her blood pressure is 78/45
mmHg. Blood cultures confirm bacteremia with
S. pyogenes. Which statement is true regarding
how the pathogen caused her septic shock?
A. The organism released a large quantity of
cytokines
B. Lipid A dysregulated the immune response
C. A virulence factor triggered the release of
TNF-α
D. An exotoxin caused direct cellular damage
• Correct answer: C
• This presentation is consistent with
sepsis based on the following:
• Bacteremia
• Fever
• Hypotension
• S. pyogenes is a gram positive organism
and contains many virulence factors
which can trigger host release of
cytokines, including TNF-α
• Since the question stem states the
patient has “septic shock”, it should
be assumed the patient requires a
vasopressor
• Choice A is incorrect because this implies
that S. pyogenes directly releases cytokines
• Choice B is incorrect because lipid A is found
only on gram negative bacteria
• Choice D is incorrect because cellular
damage does not cause sepsis (host
response to virulence factors cause sepsis)

REVIEW QUESTIONS
3. A 30-year-old man with bloody diarrhea is
diagnosed with a Shigella infection. Which
statement describes the mechanism through
which Shiga toxin alters host cell activities?
A. Inhibition of an elongation factor
B. Gαs subunit stimulation
C. Ribonucleotide removal on rRNA
D. Increased levels of cAMP
• Correct answer: C
• Shiga toxin and Shiga-like toxins both
inhibit protein synthesis by removing
adenine (a ribonucleotide) from the
rRNA of the 60S ribosomal subunit
• Choice A is incorrect because this describes
the mechanism of diphtheria toxin and
exotoxin A from Pseudomonas aeruginosa
• Choices B and D are incorrect because these
describe the mechanism by which cholera
toxin and the heat-labile toxin (HT) of ETEC
cause watery diarrhea
19
?
4. A 15-year-old male is infected with a bacterial
organism that releases an exotoxin. The role of
this exotoxin is to prevent the release of glycine
in the synaptic cleft of neurons. This describes
which exotoxin?
A. Alpha toxin
B. Tetanospasmin
C. Botulinum toxin
D. Streptolysin O
E. Erythrogenic exotoxin A
• Correct answer: B
• Glycine and GABA (γ-aminobutyric acid)
are inhibitory neurotransmitters
• Tetanospasmin prevents the release
of these neurotransmitters, leading to
motor disinhibition
• Choices A and D are incorrect because these
exotoxins disrupt cell membranes and cause
myonecrosis and necrotizing fasciitis
• Choice C is incorrect because botulinum
toxin prevents the release of ACh, leading to
paralysis
• Choice E is incorrect because is a
superantigen that causes shock
20

Section 3 - Bacterial Genetics

I. Genetic mutations, alterations, and exchange are significant because these activities can increase the virulence of
bacteria.

Genetic
Direction Speed Description Significance
Change
Random • Increased virulence
Vertical Slow • Genes randomly mutated over time
mutation • Antibiotic resistance
Phase and • Genes are randomly turned on or off within a
antigenic Vertical Fast bacterium → antigenic or structural changes • Increased virulence
variation (e.g. change to capsule, loss of pili)
• Naked bacterial DNA enters cytoplasm of
competent bacteria (S. pneumoniae, N. • Increased virulence
Transformation Horizontal Fast meningitidis, H. influenzae type b) • Utilized often in
• Donor DNA is incorporated into recipient laboratory research
chromosome
• F+ cell transfers plasmid to F─ cell → recipient
cell becomes F+ cell
• Plasmid integrates into chromosome → Hfr
• Increased virulence
Conjugation Horizontal Fast cell → some genes copied and transferred →
• Antibiotic resistance
recipient becomes recombinant F─ cell
• Hfr cell excises plasmid genes → novel plasmid
transferred → recipient becomes F’ cell
• Bacteriophage injects viral DNA into host →
viral DNA replicates and breaks up the host
chromosome (lytic phage)
Generalized • Viral capsids are formed and inadvertently
Horizontal Fast • Increased virulence
transduction include host DNA → bacteria is destroyed and
viral progeny released (lytic cycle)
• Viral progeny find new bacterial host and inject
newly-acquired bacterial DNA
• Bacteriophage injects viral DNA into host
→ viral DNA is incorporated into the host
chromosome and remains dormant (lysogenic • Increased virulence
phage; prophage) (S. pyogenes
• When triggered, viral DNA is excised from erythrogenic toxin,
Specialized the host chromosome, inadvertently excising Botulinum toxin,
Horizontal Fast
transduction bacterial genes → viral DNA replicates and Cholera toxin,
lyses the host cell (lytic phage) Diphtheria toxin,
• Lysogenic conversion: When the prophage Shiga toxin)
DNA produces gene products that enhance • Antibiotic resistance
the virulence of the host bacteria (exotoxins)
before entering the lytic cycle
Table 5.1.4 - Mechanisms of genetic change in bacteria
 21

Figure 5.1.19 - Transformation in bacteria

Figure 5.1.17 - Random mutation in bacteria

Figure 5.1.18 - Phase variation in bacteria

22

Figure 5.1.20 - Conjugation in bacteria

 23

Figure 5.1.21 - Generalized transduction (lytic cycle)

24

Figure 5.1.22 - Specialized transduction (lysogenic cycle)

II. Restriction modification system
A. Bacteria produce “DNAases” (eg, restriction
endonucleases) to degrade invading viral DNA
→ foreign DNA cannot be incorporated into
host genome
B. Bacteria methylate their own DNA at certain
regions to protect it from enzyme degradation
C. Bacteria can destroy themselves if methylation
fails
 25

Figure 5.1.23 - Restriction modification

III. Transposable elements
B. Lack of selective pressures → genes (e.g.
A. DNA segments (transposons) can excise
plasmids) that confer virulence are not
themselves and integrate somewhere else
advantageous → decreased virulence
1. From plasmid integrates into bacterial
chromosome
2. From bacterial chromosome into plasmid
3. From bacterial chromosome to another part
of the chromosome
B. Create plasmids resistant to multiple drugs

I. Loss of virulence
A. Selective pressures → bacteria with
advantageous genes become more abundant →
increased virulence
26

REVIEW QUESTIONS
1. A colony of F─ bacteria is introduced to a
novel culture medium in the absence of other
competing bacteria. After a period of time,
the bacteria is examined from two different
areas of the culture medium. The bacteria
from one area (A) has produced a slime
layer of polysaccharides that was not initially
present. Bacteria from the second area (B)
has not produced this slime layer, and are less
abundant than the bacteria in area B. The
researchers conclude that the slime layer was
initially produced by one bacterium in the first
generation. Which of the following processes
describes how bacteria in area A began
producing the slime layer?
?
• Choices A and D are incorrect because there
were no other bacterial species within the
growth medium from which gain new genes
through transformation or conjugation
• Choice B is incorrect because there is no
evidence of bacteriophages within the
medium
• Choice E is incorrect because random
mutations that would lead to a slime layer
would’ve been present in the bacteria from
the start of its life, not suddenly part way
through its life

A. Transformation
B. Specialized transduction
C. Phase variation
D. Conjugation
E. Random mutation

• Correct answer: C
• The question stem describes phase
variation:
• Within the first generation, a single
bacterium started producing a slime
layer which it had not produced
earlier in its life → the change
was sudden, not gradual over
generations → genes must have
been turned on

Section 4 - Prion Diseases
1. Prying: prion diseases
2. Sponge character holding a brain: spongiform
encephalopathy
3. Brain juices (CSF) pooling in the shape of “14-3-3”:
14-3-3 proteins are found in CSF of infected patients
4. Punching the fish with the scissors: prions are
protease resistant
5. Helical weapon knocking fish into hanging sheets:
pathologic prions convert normal prion proteins
from an α-helical configuration (PrPc) to a β-pleated
sheet formation (PrPsc)
6. Fish tripping into sheets and getting other fish
tangled in sheets: β-pleated sheet proteins convert
other proteins into more β-pleated sheets
27
7. Taxi: causes ataxia
8. Demon shouting: causes dementia
9. Crab man run over and killed: causes death
10. Sea-cows hanging outside butcher shop: can be
caused by “Mad cow disease” (bovine spongiform
encephalopathy)
11. Squid family with insomnia and one dead: can be
caused by fatal familial insomnia
12. A cross in a field: can be caused by Creutzfeld-Jakob
disease (CJD)
13. Snail eating the deceased snail: can be acquired via
Kuru (tribal cannibalism)
14. Chained up autoclave: prions are autoclave-resistant
 28

REVIEW QUESTIONS ?
1. A 65-year-old male with dementia passes away.
It is reported that he had difficulty walking and
experienced frequent falls. His family requests
that an autopsy be performed in order to
provide a definitive diagnosis. A biopsy of his
brain is obtained and shown below.

Photo Credit: Jensflorian [CC BY-SA 3.0 (https://creativecommons.org/

licenses/by-sa/3.0)]
Figure 5.1.24 - Brain biopsy with vacuolations from
spongiform encephalopathy

Photo Credit: CDC (public domain) via Wikimedia Commons

• Which of the following describes the
proteins responsible for neuronal cell death
in this patient’s brain?

A. PrPc; α-helical
B. PrPc; β-sheet
C. PrPsc; α-helical
D. PrPsc; β-sheet

• Correct answer: D
• The patient has spongiform
encephalopathy based on the following:
• Ataxia
• Dementia
• Vacuolations in brain biopsy
• Pathologic prions (PrPsc) are in the
β-sheet configuration
• Choice A is incorrect because pathologic
prions are not in the α-helical configuration
and PrPC describes normal prions
• Choice B is incorrect because PrPC describes
normal prions
• Choice C is incorrect because pathologic
prions are not in the α-helical configuration
 29

Section 5 - Introduction to Fungi

I. Fungi structure

Figure 5.1.25 - Fungi structure

II. Types of fungi
A. Two major types:
1. Filamentous (hyphae and mycelia)
2. Yeast

Figure 5.1.26 - Filamentous fungus

 30

Photo Credit: (left) Bob Blaylock [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]; (right) Microrao [Public domain]
Figure 5.1.27 - Mold (left) and yeast (right)
III. Monomorphic and dimorphic
A. Monomorphic
1. Fungi that only exist as one form (yeast or
mold)
B. Dimorphic
1. Fungi that exist in the form of both yeast
and mold
2. Environmental conditions dictate
morphological features
3. Mnemonic: “mold in the cold and yeast in Photo Credit: CDC [Public domain]

the heat” Figure 5.1.28 - Spores of Aspergillus

C. Fungal spores
1. A dormant cell designed to survive harsh
conditions
2. Structurally distinct from bacterial
endospores
3. Less durable than bacterial endospores
4. Important for fungal asexual reproduction
5. Produced by almost all fungi
 31

REVIEW QUESTIONS ?
1. A 2-year-old boy has a diaper rash due to the
fungal organism known as Candida albicans.
Targeting of which of the following structures
would be most helpful in treating this patient’s
condition?
A. Mitochondria
B. Ergosterol
C. Cholesterol
D. Protein synthesis

• Correct answer: B
• This patient has a diaper rash caused by
Candida albicans
• The basis of the question is regarding
which structure is unique to fungi
• Ergosterol is present in the plasma
membrane of fungi and is a unique
molecule from human cells which
makes it an important antifungal drug
target (eg, nystatin)
• A, C, and D are wrong because these are
features of both fungi and human cells
so targeting of these structures would
most likely harm both types of cells and
ultimately be unhelpful or even harmful
 32

Section 6 - Viral Structures

I. Viral structures
A. Envelopes
1. Lipid bilayer that surrounds the capsid
2. Lack of envelope = naked virus
B. Capsids
1. Protein structure that surrounds nucleic acids
2. Icosahedral
3. Helical

Figure 5.1.29 - Enveloped virus structures

II. Viral entry
A. Enveloped viruses
1. Adsorption: viral particles on lipid envelope
attach to host cell
2. Penetration: lipid membranes fuse and viral
capsid enters cell
3. Uncoating: capsid releases nucleic acids
B. Naked viruses
1. Adsorption: viral particles on capsid attach
to host cell
2. Penetration: cell brings in viral capsid
through endocytosis
Figure 5.1.30 - Naked virus structures 3. Uncoating: capsid releases nucleic acids
 33

Figure 5.1.31 - Adsorption, penetration, and uncoating of naked viruses

Figure 5.1.32 - Adsorption, penetration, and uncoating of enveloped viruses

III. Viral disinfection using alcohol and chlorhexidine
A. Disinfection: inactivation of most pathogens
B. Sterilization: inactivation of all pathogens
C. Alcohol and chlorhexidine destroy lipid
membranes
D. Enveloped viruses: lipid envelope destroyed →
loss of viral particles → no adsorption → not
infectious
E. Naked viruses: viral particles intact on capsid →
adsorption intact → infectious

IV. Bacteriophages
A. A virus that infects bacteria
B. Responsible for the lytic cycle and the lysogenic
cycle
Figure 5.1.33 - Bacteriophage structure
34

REVIEW QUESTIONS ?
1. A research study is evaluating the efficacy of
disinfection using chlorhexidine. Every time
a patient is discharged, pathogens present
on counter surfaces are assessed and listed.
Chlorhexidine is then used to wipe down the
surface. Following disinfection, the researchers
find that all of the bacteria are killed and most
of the viruses are inactivated. However, some of
the viruses remain viable after this procedure.
The surviving viruses must possess which of the
following?
A. A capsid protein for adsorption
B. A bilayer made of phospholipids
C. A double-stranded genome
D. A single-stranded genome

• Correct answer: A
• Chlorhexidine works primarily by
disrupting lipid membranes (i.e.
destruction of bacteria and enveloped
viruses)
• Naked viruses have proteins on their
capsid that allow adsorption and entry
into host cells
• Choice B is incorrect because this describes
enveloped viruses
• Choices C and D are incorrect because
naked viruses may be double-stranded or
single-stranded, so this detail cannot be
determined by the information provided
 35

Section 7 - Viral Genetics

I. Viruses can exchange genetic information with other viruses, leading to novel strains. Many genetic activities
alter the genome of the virus, while other activities only lead to temporary phenotypic changes (eg, phenotypic
mixing and complementation).

Genome
Genetic Activity Description
Altered
Recombination Yes • Two chromosomes cross over at homologous regions
Reassortment • Segmented viruses exchange genetic material → genetic (antigenic) shift
Yes
(genetic shift) • Example: pandemics due to influenza-related genetic shift
Random mutation
Yes • Slow, gradual changes to the viral genome
(genetic drift)
• An accidental relationship
• Virus A and virus B infect the same cell → surface proteins from virus B are used to
coat virus A
Phenotypic mixing No • Progeny: virus B surface proteins determine tropism (which cells they can infect)
and surround virus A genome → host cells infected with progeny replicate only
virus A genome → new progeny have original genotype and phenotype of virus A
• Example: HIV capsid within Rhabdovirus envelope
• A dependent relationship
• Virus A and virus B infect the same cell → virus A provides products necessary for
Complementation No virus B to infect or replicate → virus B is now infectious but continually depends on
virus A
• Example: HDV requires HBsAg for adsorption (HBV complements HDV)
Table 5.1.5 - Genetic adjustments and activities in viruses

Figure 5.1.34 - Genetic shift and genetic drift

36

Figure 5.1.35 - Phenotypic mixing

Figure 5.1.36 - HDV superinfection

 37

REVIEW QUESTIONS ?
1. 1. Researchers isolate a virus (A) capable • Correct answer: B
of invading and replicating within human • Virus A genome coated with virus B
pharyngeal tissue only. Pharyngeal tissue surface proteins refers to phenotypic
infected with virus A is examined and mixing
researchers confirm the presence of a second • Virus B surface proteins will allow
virus (B). Virus B is capable of infecting the hybrid virus A progeny to enter
pharyngeal and intestinal tissues. Virus A and intestinal mucosal cells → tropism has
B have nonsegmented genomes. Viral progeny altered
from the pharyngeal tissue have the nucleic
acids of virus A with surface proteins from
virus B. Which term best describes the hybrid
progeny?
A. Genetic shift
B. Altered tropism
C. Dependence
D. Genomic change

• Choice A is incorrect because genetic shift

refers to reassortment which only occurs
with segmented viruses
• Choice C is incorrect because dependence
refers to complementation, but virus A is
capable of completing its life cycle without
the surface proteins of virus B
• Choice D is incorrect because phenotypic
mixing is a temporary change, not a
genomic change
38

Section 8 - Viral Genomes and Replication

I. Viral genomes III. Infectivity of purified viral genomes

A. RNA viruses are single-stranded (ssRNA) A. Purified nucleic acids = all but nucleic acids have
B. Reoviruses are double-stranded (dsRNA) been removed

C. DNA viruses are double-stranded (dsDNA) B. Infectious (if injected directly into host cells)
following purification
D. Parvoviruses are single-stranded (ssDNA)
1. Positive-stranded RNA viruses
II. Positive and Negative Sense RNA 2. DNA viruses (except poxviruses and HBV)
A. Positive sense RNA C. Not infectious (even if injected into host cells)
following purification
1. Resembles eukaryotic mRNA
1. Negative-stranded RNA (lacks RdRP)
2. Can be immediately translated upon entry
to the host cytoplasm 2. Poxviruses (requires its own DNA-
dependent RNA polymerase)
B. Negative sense RNA
3. HBV (requires its own DNA polymerase)
1. Must first be transcribed to a positive sense
strand
2. These viruses carry their own RNA-
dependent RNA polymerase to create the
positive sense strand (eukaryotic cells lack
RdRP)

Figure 5.1.37 - Positive-sense and negative-sense viruses

 39

Figure 5.1.38 - Poxvirus cytoplasm replication

Figure 5.1.39 - HBV structure

IV. Translation and replication
A. Translation → new proteins
1. Protein products include everything needed
to make new virions (eg, capsids, viral
particles for adsorption, polymerases for
replication) Figure 5.1.40 - RNA virus replication
B. Replication → copy viral genome
1. RNA viruses replicate in the cytoplasm
2. DNA viruses replicate in the nucleus (except
for poxviruses)
40
REVIEW QUESTIONS
1. Newly synthesized virions of a DNA virus obtain
Figure 5.1.41 - DNA virus replication
V. Polymerases in viruses
A. RNA-dependent RNA polymerase
1. Found only in negative sense RNA viruses
2. Negative strand is transcribed into a positive
strand (mRNA)
B. RNA-dependent DNA polymerase (reverse
transcriptase)
1. Found only in retroviruses (HTLV and HIV) as
well as HBV
VI. Envelope formation
A. New virions will acquire their envelope from the
plasma membrane of the host cell
B. Herpesviruses acquire their envelope from the
nuclear membrane
?
a lipid bilayer from the cell membrane of a
eukaryotic host cell. This virus is not known
to infect hepatic cells. Which of the following
occurred at some point during the life cycle of
this virus?
A. DNA formation from an RNA-dependent
polymerase
B. RNA formation from an RNA-dependent
polymerase
C. Lipid membrane fusion with host cells
D. Invagination of host cell membrane
• Correct answer: C
• The DNA virus in question is enveloped
based on the fact that it obtained a lipid
bilayer from the host cell
• Enveloped viruses enter the host cell
through fusion of their lipid membrane
with the cytoplasmic membrane of the
host cell
• Choice A is incorrect because this describes
reverse transcriptase, a polymerase used
only by retroviruses (HIV and HTLV) and HBV
• Retroviruses are RNA (the virus in
question is DNA)
• HBV infects hepatic cells (the virus in
question does not infect hepatic cells)
• Choice B is incorrect because this describes
RNA-dependent RNA polymerase, which is
carried only by negative-sense RNA viruses
• Choice D is incorrect because this describes
endocytosis, which is how naked viruses
enter host cells
 41

BACTERIA

Figure 5.2.1 - Bacteria overview figure

42
Section 1 - Clostridium tetani
1. “Tethered to the gates of hell”: Clostridium tetani
2. Purple background: gram positive
3. Arched back: spasms of the spinal extensor muscles
(arched back appearance)
4. Green gas: produces tetanospasmin (an exotoxin
that causes muscle contractions)
5. Dice: diazepam can be used to reduce the muscle
spasms
6. Missing jaw near lock of coffin: lockjaw
7. Snails with hard shells: spore-forming
8. Belly ring with dirty rope: unhygienic deliveries and
umbilical cord care can be associated with infection
9. Mask: obligate anaerobe
10. Eerie grin: risus sardonicus (eerie grin)
11. Horns: tetanus toxin (tetanospasmin) travels to the
anterior horn of the spinal cord
12. Monster snared to the ground: the toxin cleaves
SNARE proteins
13. Gabe’s coffin: GABA is inhibited
14. Gliding Gabe: glycine is inhibited
15. Saw: renshaw cells
16. Rusty nails on robe: rusty nail puncture wounds may
precede clinical symptoms
17. Clenched hand: clenched hands
18. Syringe in the hand: infection can be prevented with
the tetanus vaccine
19. Y-shaped immunoglobulins: human tetanus immune
globulin is used to treat an acute infection
 43

REVIEW QUESTIONS ?
1. A 13-year-old unvaccinated boy presents to
the emergency department due to involuntary
muscle contractions. Physical examination
reveals neck stiffness, clenched hands, and a
decreased ability to open his jaw. The organism
most likely responsible for this patient’s
symptoms produces a toxin that cleaves what
protein?

• Correct answer: SNARE proteins

 
Photo Credit: Y tambe [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC
BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia
Commons
Figure 5.2.2 - Gram stain
• The patient is unvaccinated and is having
involuntary muscle contractions
• Decreased ability to open jaw → lockjaw
• Clostridium tetani produces tetanospasmin
which cleaves SNARE proteins

Photo Credit: Content Provider(s): CDC/Don Stalons [Public domain], via

Wikimedia Commons
Figure 5.2.3 - Gram-positive bacilli

Figure 5.2.4 - Tetanospasmin

 44
Section 2 - Clostridium botulinum
1. Underground robot fighting: Clostridium botulinum
2. Purple in the background: gram positive
3. Crime lord’s mask: obligate anaerobe
4. Can-shaped robot: improperly canned food can
cause infection in adults due to ingestion of
preformed toxin
5. Missing leg: descending paralysis
6. Weaponized honey: ingestion of spores in honey
can cause infant botulism
7. Small, floppy robot: floppy baby syndrome
8. M&M’s: spore-forming
9. Ensnared robot in honey: exotoxin cleaves SNARE
proteins
10. Seed on head: toxin prevents release of
acetylcholine
11. Open mouth: dysarthria
12. Crime lord’s sunglasses: blurred vision
13. Crime lord’s bowtie: botox injections can be used for
therapeutic and cosmetic reasons
14. Fight ring with y-shaped spikes: treat with human
botulinum immunoglobulin
 45

REVIEW QUESTIONS ?
1. A 33-year-old female presents to the physician
due to recurrent and chronic migraines. She
has tried multiple medications but nothing
seems to alleviate her symptoms. The physician
recommends treatment with a medication
known to cause focal paralysis of the injected
region. This drug most likely prevents the
release of what neurotransmitter?

• Correct answer: acetylcholine

Photo Credit: CDC/Dr. George lombard [Public domain]
Figure 5.2.5 - Gram stain of Clostridium botulinum
• Medication being described is botox
• Botox is used to treat chronic migraines and
causes focal paralysis of the injected region
• Botox is diluted Clostridium botulinum toxin
so it must work by cleaving SNARE proteins
associated with the release of acetylcholine
into the synaptic cleft
 46
Section 3 - Clostridium difficile
1. Difficult army training course: Clostridium difficile
2. Purple background: gram-positive
3. Flowers: normal intestinal flora
4. Snails in the mud: spore-forming
5. Mud tester wearing mask: obligate anaerobe
6. Mud tester wearing mask and gloves: contact
precautions including non-sterile gloves and a gown
are important in preventing infection
7. Cleaning guy: prior antibiotic exposure (especially
clindamycin) increases risk of infection
8. Poop pumper: patients taking PPIs are at an
increased risk of infection
9. Drill sergeant “A”: toxin A (enterotoxin)
10. Bucket of poop: toxin A causes intestinal
inflammation and fluid secretion
11. Drill sergeant “B”: toxin B (cytotoxin)
12. Drill sergeant “B” kills recruit: toxin B can induce
cellular apoptosis
13. Skull on shoulders: toxin A and toxin B disrupt
the integrity of the cytoskeleton within intestinal
mucosal cells
14. Tire obstacles: toxin A and toxin B cause
pseudomembranous colitis and diarrhea
15. Climbing chains: diagnosed using PCR (detects the
genes that code for toxin B)
16. Mud tester collecting poop: diagnosed with a stool
sample
17. Big army van: treat with oral vancomycin
18. Metro for recruit transportation: treat with
metronidazole
19. Fit guy holding axe: treat with fidaxomicin
20. Transplanted flower: fecal microbiota transplant
may be considered in recurrent cases
 47

REVIEW QUESTIONS ?
1. A 73-year-old female is brought to the
emergency department due to fevers, nausea,
vomiting, and flank pain. Physical examination
reveals costovertebral angle tenderness.
After thorough evaluation she is treated with
levofloxacin for pyelonephritis. Several days
later her symptoms begin to resolve, but she
develops watery diarrhea and abdominal
pain. Nucleic acid amplification testing of the
patient’s stool reveals the presence of the tcdB
gene which encodes for a toxin produced by a
gram-positive organism. Which of the following
is most likely true regarding the toxin?

A. It activates adenylate cyclase

B. It inactivates the 60S ribosomal subunit
Photo Credit: CDC/Dr. Holdeman, Courtesy: Public Health Image Library C. It disrupts the integrity of the cytoskeleton
Figure 5.2.6 - Gram stain of Clostridium difficile D. It cleaves SNARE proteins

• Correct answer: C
• This patient has a C. diff infection
• The patient was treated with antibiotics
(levofloxacin) and then developed
watery diarrhea
• Antibiotic exposure (not just
clindamycin) is a risk factor for C. diff
infections
• Nucleic acid amplification testing
revealed the presence of a gene that
encodes for a toxin produced by a gram-
positive organism
• Toxin A and toxin B produced by C.
diff both disrupt the integrity of the
cytoskeleton
• A is incorrect because this is describing the
Photo Credit: User: Samir [CC BY 3.0 (https://creativecommons.org/licenses/
mechanism of other microorganisms (eg,
by/3.0)] Vibrio cholerae, enterotoxigenic E. coli, and
Figure 5.2.7 - Pseudomembranous colitis Bacillus anthracis), but these are unlikely
to suddenly cause symptoms in a patient
recently treated with an antibiotic.
• B is describing the mechanism of
the toxin produced by Shigella and
enterohemorrhagic E. coli
• D is describing the mechanism of the
toxin produced by Clostridium tetani
and Clostridium botulinum but these are
associated with muscle spasms or paralysis
and not diarrhea.
 48
Section 4 - Clostridium perfringens
1. Clown with perfume: Clostridium perfringens
2. Purple background: gram positive
3. Rice Krispie Treats: crepitus
4. Man about to vomit: heat-labile enterotoxin causes
food poisoning
5. Pot full of dirt: commonly found in soil
6. Alpha house sign: produces α toxin
7. Dum dum suckers stuck in pumpkin: the α toxin
(lecithinase) is a phospholipase
8. Smashed pumpkin: degrades tissue and cell
membranes (hemolysis)
9. Pumpkin seeds: spore-forming
10. Crow: causes myonecrosis
11. Gang of kids: causes gas gangrene
12. Kids wearing masks: obligate anaerobe
13. Murderer killing two people with two streaks of
blood: “double zone” of hemolysis on blood agar
14. Janitor cleaning mess: treat with clindamycin
 49

REVIEW QUESTIONS ?
1. A 27-year-old female presents to the emergency
department due to a wound from a garden rake
that penetrated her leg. Over the next several
hours she develops intense pain and edema
over the injured leg. Crepitus is present on
physical examination. The organism most likely
responsible for this patient’s condition produces
a toxin with what mechanism of action?

Photo Credit: Content Provider(s): CDC/Don Stalons [Public domain], via • Correct answer: degrades the cell
Wikimedia Commons membrane
Figure 5.2.8 - Gram stain of Clostridium perfringens • This patient sustained an injury from a
dirty garden rake (wounds contaminated
with dirt increase the risk of infection by
Clostridium perfringens)
• Crepitus is highly suggestive of Clostridium
perfringens
• Clostridium perfringens produces alpha
toxin which is a phospholipase that
degrades cell membranes

Photo Credit: Engelbert Schröpfer, Stephan Rauthe and Thomas Meyer. [CC BY
2.0 (https://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
Figure 5.2.9 - Gas gangrene
50
Section 5 - Bacillus anthracis
1. Giant ant hill: Bacillus anthracis
2. Purple tents: gram positive
3. Mounds extending away from ant hill: “Medusa
head”
4. Wool coat and boots: increased risk in those who
handle wool (woolsorter’s disease)
5. Girl holding inhaler: grows well under aerobic
conditions
6. M&Ms on ground: spore-forming
7. Edamame: edema factor (exotoxin)
8. Tents: edema factor mimics adenylate cyclase
(increases cAMP)
9. Backpack protecting girl from ants: protective
antigen
10. Sign with skull: lethal factor
11. Ant “mates" glued together: polypeptide capsule
(contains D-glutamate)
12. Coughing up red M&Ms: pulmonary anthrax causes
pulmonary hemorrhage
13. M&Ms near mediastinum: pulmonary anthrax
causes mediastinitis with widened mediastinum on
CXR
14. Black ant biting hand: ulcer with black eschar seen
in cutaneous anthrax
15. Flower staff: fluoroquinolones are an effective
treatment
 51

REVIEW QUESTIONS ?
1. A 37-year-old male is admitted to the hospital
due to 3 days of fever, shortness of breath, and
a recent episode of hemoptysis. He works as a
shepherd during the summers, has no smoking
history, and denies any recent travel. A sputum
gram stain reveals gram-positive rods. Which of
the following is most likely true regarding the
microorganism?
A. The polysaccharide capsule is
antiphagocytic
Photo Credit: https://commons.wikimedia.org/wiki/File:Bacillus_anthracis_
Gram.jpg B. One component of the exotoxin complex
Figure 5.2.10 - Gram stain of Bacillus anthracis results in increased levels of cAMP
C. The toxin inactivates elongation factor (EF-
2)
D. It is an obligate anaerobe

• Correct answer: B
• This patient has pulmonary anthrax
• Hemoptysis, shepherd work, and a gram
stain showing gram-positive rods
• Bacillus anthracis produces edema
factor which mimics the effects of
adenylate cyclase → ↑ cAMP
• A is incorrect because while capsules are
antiphagocytic, bacillus anthracis has a
polypeptide capsule - not a polysaccharide
capsule
Photo Credit: Content Provider(s): CDC [Public domain], via Wikimedia • C is incorrect as this is describing the
Commons
Diphtheria toxin (EF-2 is associated with
Figure 5.2.11 - Cutaneous anthrax protein synthesis which is not directly
affected by bacillus anthracis)
• D is incorrect because bacillus anthracis is
an aerobe - not an anaerobe
 52
Section 6 - Bacillus cereus
1. Bowl of rice: Bacillus cereus
2. Purple shirt: gram positive
3. Rod-shaped walking stick: bacilli
4. Hemp seeds: spore forming
5. Cooking rice and hemp seeds over fire: spores can
withstand being cooked in rice
6. Toxic green smoke: enterotoxin formation
7. “EMT” badge: emetic type
8. Eating rice: emetic type is associated with rice and
pasta
9. Rice cereal: emetic type produces cereulide toxin
10. Vomiting: emetic type causes vomiting
11. Five fingers: emetic type occurs 1-5 hours after
ingestion of toxin
12. Guy sitting in puddle of water holding abdomen:
diarrheal type results in watery diarrhea and
gastrointestinal pain
13. “I voted” sticker: diarrheal type occurs 8-18 hours
after ingestion of toxin
 53

REVIEW QUESTIONS ?
1. An 8-year-old boy presents to the emergency
department due to 6 hours of nausea, vomiting,
and abdominal pain. He reports eating pasta
at an Italian restaurant earlier today. He
denies diarrhea, bloody stool, or recent travel.
Physical examination reveals diffuse abdominal
tenderness to palpation. Which of the following
is most likely true regarding this patient’s
condition?

A. It is caused by an ingested pathogen that is

Photo Credit: Y tambe [CC BY-SA 3.0 (https://creativecommons.org/licenses/ actively producing a toxin
by-sa/3.0/)], via Wikimedia Commons B. It is due to a fecalith obstruction
Figure 5.2.12 - Gram stain of Bacillus cereus C. It is associated with Henoch-Schӧnlein
purpura
D. Microscopy will reveal noncaseating
granulomas
E. A preformed toxin is responsible

• Correct answer: E
• This patient has Bacillus cereus food
poisoning
• Acute onset nausea, vomiting, and
abdominal pain after eating pasta
• The spores can withstand being cooked
and once the pasta is left at room
temperature the spores germinate
• A preformed toxin is produced that can
rapidly cause symptoms when ingested
• A is incorrect because organisms that
actively produce toxins after ingestion
usually don’t cause symptoms until 24 hours
after the ingestion of the organism.
• B is incorrect because this is describing
appendicitis.
• C is describing intussusception which is
classically associated with red “currant jelly”
stools
• D is describing Crohn disease. This typically
presents diarrhea as well as many other
manifestations such as malabsorption
problems, perianal disease, and
dermatologic abnormalities
 54
Section 7 - Listeria monocytogenes
1. Monocle: Listeria monocytogenes
2. Purple colors: gram positive
3. Rod-shaped bat: bacillus
4. Narrow river and bay: narrow zone of β-hemolysis
5. Cat: catalase positive
6. Tumbleweed: tumbling motility in broth
7. Whip cracking tail: forms “rocket tails” via actin
polymerization
8. Man with gun inside of house: rocket tails facilitate
intracellular movement and cell-to-cell spread
across cell membranes
9. Asthma inhaler: aerobe
10. Building with no roof: facultative intracellular
11. People drinking milk and eating cheese and deli
meats: acquired by ingestion of cold deli meats and
unpasteurized dairy products
12. Ice and cold water: grows well at cool temperatures
(4-10 degrees C)
13. Candle: a TORCHES organism
14. Sick pregnant woman: septicemia in pregnant
women
15. Vomit: self limited gastroenteritis in healthy
individuals
16. Vomit on pregnant belly: amnionitis in pregnant
women can lead to spontaneous abortion
17. Grandma: granulomatosis infantiseptica
18. Baby wearing hat: neonatal meningitis
19. Man on stretcher wearing hat: meningitis in
immunocompromised
20. Old time amp: an effective treatment is ampicillin
 55

REVIEW QUESTIONS ?
1. A 23-year-old pregnant female is brought to
the emergency department due to nausea,
vomiting, and diarrhea. Several hours later she
spontaneously delivers a preterm infant who
has meningitis. Upon further investigation,
the mother endorses regularly drinking
unpasteurized milk throughout her pregnancy.
Blood cultures from the mother and child reveal
gram-positive rods that exhibit tumbling motility
in broth. Which of the following would be most
Photo Credit: CDC/Bobby Strong, Courtesy: Public Health Image Library useful in eliminating the causal organism?
Figure 5.2.13 - Gram stain of gram-positive rods
A. Cytotoxic T cell activity
B. Antibody secretion
C. Complement activation
D. Ceftriaxone

• Correct answer: A
• This mother and child have infections
caused by Listeria monocytogenes
• Listeria causes gastroenteritis in healthy
individuals (eg, nausea, vomiting, and
diarrhea) and meningitis in neonates
• The mother has a history of drinking
Photo Credit: By Y tambe (Y tambe's file) [GFDL (https://www.gnu.org/ unpasteurized milk which is a risk factor
copylet/fdl.html), CC-BY-SA-3.0 (https://creativecommons.org/licenses/by-
sa/3.0/) or CC BY-SA 2.5 (https://creativecommons.org/licenses/by-sa/2.5/), for Listeria
via Wikimedia Commons • Listeria is a gram-positive rod that
Figure 5.2.14 - Hemolysis on 5% sheep blood agar exhibits tumbling motility in broth
• Listeria is a facultative intracellular
organism which means that it
is protected from antibodies,
complement, and other circulating
immune factors
• Elimination of the pathogen is reliant
upon the activity of cytotoxic T cells
Photo Credit: Philippinjl at French Wikipedia. [CC BY-SA 2.0 fr (https://
creativecommons.org/licenses/by-sa/2.0/fr/deed.en), via Wikimedia
which trigger cell lysis
Commons • B and C are both wrong because these are
Figure 5.2.15 - Catalase test largely ineffective against an intracellular
pathogen
• D is incorrect because Listeria is resistant
to third generation cephalosporins such as
ceftriaxone
56
Section 8 - Corynebacterium diphtheriae
1. Haunted corn maze: Corynebacterium diphtheriae
2. Purple background: gram positive
3. Child with lice: must first be lysogenized by a
bacteriophage before it produces a virulent exotoxin
4. Woman using asthma inhaler: aerobic
5. Woman using the telephone: tellurite agar
6. Alien: aniline dyes used to stain metachromatic
granules
7. Mist by the corn maze: transmitted through
aerosolized droplets
8. Tie around neck: pharyngitis
9. Bureau guy arresting business owner: the B subunit
binds to host cell receptors and induces endocytosis
of the toxin
10. Agency guy with extendable baton: the A subunit
inhibits elongation factor 2 (EF-2)
11. Heat lamp: fever
12. Tires: pseudomembrane formation
13. Sausage-link rope: neurotoxic
14. FBI car: cardiotoxic (myocarditis, heart block, and
arrhythmias)
15. Elk: Elek test
16. Laughing guy: Löffler’s medium
17. Syringe to pop tires: toxoid vaccine can prevent
diphtheria
18. Y-shaped suspension tools: preformed antibody
can be administered to help prevent systemic
complications
 57

REVIEW QUESTIONS ?
1. A 12-year-old boy who recently moved to
the United States from Nepal is brought to
the emergency department due to fever,
pharyngitis, and heart palpitations. His
temperature is 38.5°C but other vital signs are
normal. Physical examination is significant for
a gray exudate on the posterior pharynx. A
swab of the exudate is obtained. On microscopy
there are gram-positive rods with granules that
Photo Credit: Content Provider(s): [Public domain], via Wikimedia Commons stain deeply with aniline dyes. He is admitted
Figure 5.2.16 - Gram stain of Corynebacterium to the hospital. Which of the following should
diphtheriae be done immediately to prevent additional
complications?
A. Careful monitoring of neurological status
B. Intubation
C. Serial electrocardiograms
D. Preformed antitoxin administration
E. Vaccine administration

• Correct answer: D
• This patient has a Corynebacterium
diphtheriae infection
• Possible lack of immunization (eg,
recently moved to the US from Nepal)
• Gray exudate on the posterior pharynx
• Gram-positive rods with granules that
stain deeply with aniline dyes
Photo Credit: Nethan Hussain [CC BY-SA 3.0 (http://creative commons.org/
licenses/by-sa/3.0)], from Wikimedia Commons • The antitoxin contains antibodies that
Figure 5.2.17 - Cystine-tellurite agar inactivate the diphtheria toxin (only
useful before the toxin enters the cell so
it must be administered immediately)
• A is incorrect because administration of
preformed antitoxin is more important (any
delay may allow more of the toxin to enter
the cells)
• B is unnecessary at this point because the
boy’s respiratory rate is normal and he
doesn’t appear to be in any respiratory
distress.
• C is a good idea because diphtheria
is cardiotoxic but just like choice A -
administration of the antitoxin is more
important.
• E should also be done but the immune
response to vaccination is slow so the
Photo Credit: User:Dileepunnikri [CC BY-SA 3.0 (https://creativecommons.
antitoxin should be given first in someone
org/licenses/by-sa/3.0)], from Wikimedia Commons who is acutely ill
Figure 5.2.18 - Pseudomembranous pharyngitis
58
Section 9 - Viridans streptococci
1. Venomous villain: Viridans streptococci
2. Purple background: gram positive
3. Wide open mouth and tongue out: normal
oropharyngeal flora
4. Mutant being: Streptococcus mutans
5. Mighty warrior: Streptococcus mitis
6. Teeth: Streptococcus mitis and Streptococcus
mutans cause dental caries
7. Spider warrior: Streptococcus sanguinis
8. Alfalfa plants: α-hemolytic
9. Chin resisting web: optochin resistant
10. Spider webs adhering to buildings: produces
dextrans which adhere to areas of endothelial
trauma
11. Cars: subacute bacterial endocarditis
12. Teeth (dentistry): endocarditis after dental
procedures in patients with pre-existing valvular
lesions
13. Splinter in the foot: splinter hemorrhages
14. Green soda with ice cubes: bile insoluble
15. Pennies: treatment for endocarditis is penicillin G
16. Trident weapon: ceftriaxone
 59

REVIEW QUESTIONS ?
1. A 29-year-old female presents to the physician
due to intermittent fevers for the past 4
days. She states that she underwent a dental
procedure 3 weeks ago, but did not receive
prophylactic antibiotics. She has a history of
a pre-existing valvular lesion which occurred
several years ago. Examination of her fingers
reveals dark lesions that run vertically
underneath the nails beds. How will the causal
organism most likely be affected by optochin?
Photo Credit: Y tambe [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-
SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or CC BY0SA 2.5
(https://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons
• Correct answer: unaffected by optochin
• Intermittent fevers and dark lesions that run
Figure 5.2.19 - Gram stain of Streptococci
vertically underneath the nail beds (splinter
hemorrhages) are suggestive of bacterial
endocarditis
• A history of a pre-existing valvular
lesion and a recent dental procedure
are suggestive of an infection caused by
Viridans group streptococci
• Viridans group streptococci are optochin
resistant

Photo Credit: CDC: Dr. JJ Farmer (PHIL #3031), 1978. [Public domain], via
Wikimedia Commons
Figure 5.2.20 - Microbial resistance and sensitivity
to various compounds

Photo Credit: Splarka [Public domain], from Wikimedia Commons

Figure 5.2.21 - Splinter hemorrhages
 60
Section 10 - Streptococcus pneumoniae
1. New mower: Streptococcus pneumoniae
2. Mower is purple: gram positive
3. Alfalfa plant: α-hemolytic
4. Hero that is sensitive about his chin: optochin
sensitive
5. Lances on mower: lancet-shaped diplococci
6. Tridents: treat with ceftriaxone
7. Scarecrow: treat with macrolides
8. Quails: quellung reaction
9. Sacks of apples: polysaccharide capsule
10. Syringe on the sack: the vaccine is directed against
the polysaccharide capsule
11. Spilled green apple juice with melted ice cubes: bile
soluble
12. Guy cleaning juice with mop: MOPS (meningitis,
otitis media, pneumonia, and sinusitis)
13. Guy cutting down vegetation with a sickle: sepsis in
sickle cell disease and asplenic patients
14. Scissors: IgA protease
 61

REVIEW QUESTIONS ?
1. A 67-year-old female presents to the emergency
department due to sudden onset nausea,
vomiting, and confusion. Physical examination is
significant for a fever of 38.6°C, nuchal rigidity,
and altered mental status. Empiric treatment
is started and a lumbar puncture is performed.
CSF gram stain reveals gram-positive, lancet-
shaped diplococci. Administration of a vaccine
directed against what bacterial structure may
have been helpful in preventing infection?

• Correct answer: polysaccharide capsule

• A fever, nuchal rigidity, and altered mental
status → meningitis
• Streptococcus pneumoniae is the most
common cause of bacterial meningitis in
Photo Credit: Content Provider(s): CDC [Public domain], via Wikimedia adults
Commons
• A CSF gram stain reveals gram-positive,
Figure 5.2.22 - Quellung reaction lancet-shaped diplococci which confirms the
diagnosis of Streptococcus pneumoniae
• The vaccine targets the polysaccharide
capsule

Photo Credit: B. Welleschick [GFDL (http://www.gnu.org/copyleft/fdl.html),

CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or CC BY-SA
2.5 (https:///creativecommons.org/licenses/by-sa-2.5)], from Wikimedia
Commons
Figure 5.2.23 - Otitis media
62
Section 11 - Streptococcus pyogenes
1. Pie: Streptococcus pyogenes
2. Purple floor: gram positive
3. House on the bay: β-hemolytic
4. “Put your raincoat”: PYR positive
5. Covered pie: hyaluronic acid capsule
6. Burned hand: skin infections (cellulitis)
7. Honey on the pie: impetigo
8. Red mitten: erysipelas
9. Superhero cape: pyrogenic exotoxin (a
superantigen) causes toxic shock-like syndrome
10. Shocked baby: toxic shock-like syndrome causes
shock
11. Sweating baby: toxic shock-like syndrome causes
fever
12. Red rash on baby’s belly: toxic shock-like syndrome
causes a rash
13. Woman wearing scarf: pyrogenic exotoxin causes
scarlet fever
14. Crumbs that resemble sand: scarlet fever causes a
sandpaper-like rash
15. Scarf around neck: scarlet fever causes pharyngitis
16. Munching on a strawberry: strawberry tongue
17. Burnt pie: necrotizing fasciitis
18. O-shaped donuts that are filled with red jelly:
streptolysin O is a toxin that degrades cell
membranes and lyses RBCs
19. “S” is for strawberry: streptolysin S
20. Guy with a fever and towel on his head: rheumatic
fever
21. “Welcome to the JONES’ sign”: JONES
22. Donut jelly flying to guy with a fever:
antistreptolysin O (ASO) titers can be used to
diagnose rheumatic fever
23. Maid: M protein is a virulence factor
24. Maid quieting down noisy kids: M protein inhibits
phagocytosis
25. Maid caring for guy with fever: M protein can give
rise to rheumatic fever
26. Toy cars by maid: M protein is associated with
carditis
27. Tangled up cord in shape of glomerulus:
poststreptococcal glomerulonephritis
28. Broken bass guitar: bacitracin sensitive
29. Stressed out guy pulling on tie wrapped around
neck: pharyngitis
30. Pennies on the poker table: penicillin G used to treat
pharyngitis
31. Sapphires on the poker table: cephalexin used to
treat skin infections (impetigo)
 63

Photo Credit: RafaelLopez at the English language Wikipedia[CC BY-SA 3.0 Photo Credit: Evanherk at Dutch Wikipedia [CC BY-SA 3.0 (http://
(http://creativecommons.org/licenses/by-sa/3.0/)] creativecommons.org/licenses/by-sa/3.0/)]

Figure 5.2.24 - Cellulitis Figure 5.2.25 - Impetigo

 64

Photo Credit: CDC/Dr. Thomas F. Sellers/Emory University [Public domain] Photo Credit: Afag Azizova [CC BY-SA 3.0 (http://creativecommons.org/
licenses/by-sa/3.0/)]
Figure 5.2.26 - Erysipelas
Figure 5.2.28 - Strawberry tongue

Photo Credit: https://en.wikipedia.org/wiki/File:Pos_strep.JPG#file

Photo Credit: https://en.wikipedia.org/wiki/File:Scarlet_Fever.jpg#file
Figure 5.2.27 - Sandpaper-like rash Figure 5.2.29 - GAS pharyngitis
 65

REVIEW QUESTIONS ?
1. A 12-year-old boy comes to the office due to 2
days of a sore throat. A rapid antigen detection
test is positive for group A Streptococcus (GAS).
The physician immediately prescribes penicillin
due to concerns about a complication that
would occur if the infection was left untreated.
The complication occurs due to a virulence
factor produced by the organism which
subsequently triggers an immune response.
What is the most likely function of the virulence
factor described?

• Correct answer: resists phagocytosis

• The patient has group A strep (GAS) and
is prescribed penicillin due to concerns of
developing rheumatic fever
• Rheumatic fever is caused by M-protein
which is a virulence factor that triggers an
immune response and causes the host to
produce antibodies that target bacterial
antigens
• The bacterial antigens may be similar to
antigens present in the heart which means
that host antibodies may accidently target
the heart
• Additionally, M-protein resists phagocytosis
 66
Section 12 - Streptococcus agalactiae
1. Glacier: Streptococcus agalactiae
2. Bay: β-hemolytic
3. Purple tents: gram positive
4. Camping: CAMP factor
5. Sleep sack: polysaccharide capsule
6. Bass guitar with chains: bacitracin resistant
7. Hippies: positive hippurate test
8. Pregnant lady coughing: pneumonia in neonates
9. Guy sipping hot chocolate near pregnant lady:
sepsis in neonates
10. Hat and headband near pregnant lady: meningitis in
neonates
11. Pregnant lady: screen pregnant women at 35-37
weeks gestation
12. Pennies: pregnant women colonized with GBS
receive intrapartum penicillin prophylaxis
13. Amp: pregnant women may also be treated with
ampicillin
 67

REVIEW QUESTIONS ?
1. A 27-year-old female presents to the physician
for a follow-up visit at 37 weeks gestation.
The physician recommends vaginal and
rectal cultures to screen for colonization of a
potentially harmful microorganism transmitted
to the neonate during childbirth. The organism
of interest most likely demonstrates what type
of hemolysis?

• Correct answer: β-hemolysis

Photo Credit: By Clueiridium [CC0], from Wikimedia Commons
Figure 5.2.30 - CAMP test
• GBS may colonize the vagina and rectum
so vaginal and rectal cultures are typically
obtained at 37 weeks gestation
• GBS can be transmitted to the neonate
during childbirth
• GBS exhibits β-hemolysis on sheep blood
agar
 68

Section 13 - Streptococcus gallolyticus

1. Galileo: Streptococcus gallolyticus 6. Bloody wound: bacteremia

2. Purple colors: gram positive 7. Cart: endocarditis
3. Flowers near brown river: normal colonic flora 8. Cancer hope ribbon near muddy river: associated
4. Green gamma ray: γ-hemolytic with colon cancer
5. Green reflection in river: grows in bile
 69

REVIEW QUESTIONS
1. A 33-year-old male with a history of IV drug
use comes to the office due to recent changes
in his fingernail. Examination of the fingernail
is shown below. Physical examination is also
significant for a holosystolic high-pitched
murmur that is best heard near the left sternal
border. Blood cultures are positive for an
organism that grows well in bile but fails to
grow in the presence of 6.5% NaCl. Which of
the following is true regarding the organism
responsible for this patient’s condition?
?
• Streptococcus gallolyticus can cause
endocarditis and is associated with colon
cancer
• A is false - Streptococcus gallolyticus is
catalase-negative (Staphylococcus aureus  is
catalase-positive and can cause endocarditis
but does not grow in the presence of bile)
• B is false - Streptococcus gallolyticus is a
gram-positive coccus
• D is false - it’s not typically associated with
abdominal wound infections (this is true of
Enterococcus)
• E is false - Streptococcus gallolyticus exhibits
γ-hemolysis on blood agar

Photo Credit: Splarka [Public domain], from Wikimedia Commons

A. It is catalase positive
B. It is a gram-positive rod
C. It is associated with colon cancer
D. It is associated with abdominal wound
infections
E. It exhibits α-hemolysis on blood agar

• Correct answer: C
• The patient has endocarditis
• IV drug use
• Splinter hemorrhages (shown in the
image)
• Cardiac murmur
• Blood cultures reveal an organism that
grows well in bile but not in the presence
of 6.5% NaCl → organism must be
Streptococcus gallolyticus (Enterococci grow
in bile and 6.5% NaCl)
 70
Section 14 - Enterococci
1. “Enter” sign: Enterococcus
2. Purple colors: gram positive
3. Flowers near sewer: normal intestinal flora
4. “Put Your Raincoat”: PYR positive
5. Salt shaker: grows in 6.5% NaCl
6. Green gamma rays: γ-hemolytic
7. Green soda near growing flowers: grows in bile
8. Punched in the belly: abdominal wound infections
9. Spilled fluid on crotch: urinary tract infections
10. Car: endocarditis
11. Charging attendees a fee: Enterococcus faecium and
Enterococcus faecalis
12. Banana trees: biliary tree infections
13. Amp: treat with ampicillin
14. Line tape: treat with linezolid
15. Resistant bouncer guys near van: vancomycin
resistant
 71

REVIEW QUESTIONS
1. A 72-year-old male is admitted to the hospital
Photo Credit: Content Provider(s): CDC/Dr. Richard Facklam [Public domain]
Figure 5.2.31 - Gram stain of Enterococci
?
for community acquired pneumonia. A urinary
catheter is placed upon admission because the
patient is unable to ambulate to the bathroom.
After two days of appropriate treatment his
symptoms begin to resolve. However, on the
third day of admission he begins to experience
dysuria, frequency, and urgency. A urine culture
grows gram-positive cocci in pairs and chains.
Antibiotic sensitivity testing reveals that the
organism is resistant to vancomycin. The causal
organism will most likely demonstrate which of
the following?
A. Beta hemolysis on blood agar
B. PYR positivity
C. Absence of growth in hypertonic (6.5%)
saline
D. Water and oxygen production in the
presence of hydrogen peroxide

• Correct answer: B
• Reasons why Enterococcus is the most likely
organism:
• UTI (dysuria, frequency, and urgency
following placement of a catheter)
• Morphology of the organism (gram-
positive cocci in pairs and chains)
• Ability to resist vancomycin
• Enterococcus is PYR positive
• A is wrong because Enterococcus is
γ-hemolytic
• C is wrong because Enterococcus grows well
in the presence of 6.5% NaCl
• D is describing the catalase test and
Enterococcus is catalase-negative
 72
Section 15 - Staphylococcus aureus
1. Merlin’s staff: Staphylococcus aureus
2. Purple background: gram positive
3. Merlin’s cat: catalase positive
4. Bay: β-hemolytic
5. Tall man: ferments mannitol
6. “A” on shield: protein A prevents opsonization and
phagocytosis
7. Fire coming out of dragon’s nose: colonizes the
nares
8. Coagulated blood: coagulase positive
9. Fire scalding man’s skin: scalded skin syndrome
10. Man vomiting: rapid-onset food poisoning
11. Guy getting shocked: toxic shock syndrome
12. Guy getting shocked is wearing a superhero cape:
TSST-1 is a superantigen (causes binding of MHC
class II and T cell receptors → ↑ cytokine release →
shock)
13. Tissue packed in nose: classically associated with
prolonged use of a tampon or nasal packing
14. Guy vomiting: vomiting
15. Guy is getting shocked: shock
16. Rash with skin falling off: desquamating rash
17. Dragon scales: osteomyelitis
18. Red knees: septic arthritis
19. Guy near mosquitos is coughing due to smoke: post-
viral bacterial pneumonia
20. Burns on arm: skin infections and abscesses
21. Chest of myrrh: MRSA
22. Bricks (i.e. altered wall) on ground causing myrrh
chest to fall off of cart: MRSA have altered penicillin
binding proteins
23. Caravan: vancomycin is effective against MRSA
24. Sapphires: cephalexin for non-MRSA infections
25. Vials of drugs on cart: endocarditis in IV drug users
 73

REVIEW QUESTIONS ?
1. A 27-year-old female presents to the emergency
department due to a 5-hour history of fever,
rash, and altered mental status. Her blood
pressure is 76/58 and she is tachycardic. She
is examined thoroughly and a used tampon is
removed from the vagina. A gram stain of a
nasal swab specimen reveals gram-positive cocci
Photo Credit: By Y Tambe (Y Tambe) [GFDL (http://www.gnu.org/copyleft/fdl. in clusters. The organism most likely responsible
html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via for this patient’s presentation produced the
Wikimedia Commons
systemic syndrome through which of the
Figure 5.2.32 - Gram stain of Staphylococcus
following mechanisms?
A. Overactivation of cAMP
B. Lecithinase-mediated degradation of tissue
C. Toxin B-mediated disruption of the
cytoskeleton
D. Excessive release of cytokines

• Correct answer: D
• Reasons why Staphylococcus aureus is the
most likely organism:
• The patient has toxic shock syndrome
(fever, rash, altered mental status,
hypotension, and the presence of a
used tampon in the vagina)
• A nasal swab showed gram-positive
Photo Credit: Navaho [CC BY-SA 4.0 (https://creativecommons.org/licenses/ cocci in clusters
by-sa/4.0)]
• Toxic shock syndrome is caused by toxic
Figure 5.2.33 - Mannitol fermentation test
shock syndrome toxin 1 (TSST-1)
• This is a superantigen which causes binding
of MHC class II and T-cell receptors resulting
in overactivation of T-cells → excessive
release of cytokines
• A is true of several toxins but
Staphylococcus aureus does not affect cAMP
• B is describing the alpha toxin of Clostridium
perfringens
• C is describing the toxin of Clostridium
difficile

Photo Credit: Philippinji [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-

BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia
Commons
Figure 5.2.34 - Coagulase test tube
74

Section 16 - Staphylococcus epidermidis

1. Dermatology clinic: Staphylococcus epidermidis 6. Cat: catalase positive

2. Purple background: gram positive
3. Flowers: normal skin flora
4. Bison vulnerably sitting on operating table:
novobiocin sensitive
5. Spattered bison blood: frequently contaminates
blood cultures
7. Urine: urease positive
8. Biofilm on the pipe: produces an adherent biofilm
9. Foreign body stuck in bison: infects foreign bodies
10. Tools with tubes: infects IV catheters
11. Car: can cause prosthetic valve endocarditis
12. Van: vancomycin is an effective treatment
 75

Photo Credit: https://www.flickr.com/photos/36349503@N08/3368611155

Figure 5.2.35 - Urease test

REVIEW QUESTIONS
1. A 39-year-old male is admitted to the hospital
due to a fever of 38.7 C and a cardiac murmur.
He recently had his aortic valve replaced due
to degeneration of a congenital bicuspid aortic
valve. Blood cultures are obtained and grow
coagulase-negative staphylococci. Which of
the following is most likely true regarding this
organism?
A. It produces an adherent biofilm
B. It releases an exotoxin into the bloodstream
C. It is urease negative
D. It is novobiocin resistant
?
• Staphylococcus epidermidis produces an
adherent biofilm that is made up of an
extracellular polysaccharide matrix that
acts as a barrier to antibiotics and the
immune system
• B is false because Staphylococcus
epidermidis doesn’t produce an exotoxin
• C is D are false because Staphylococcus
epidermidis is urease positive and
novobiocin sensitive (Staphylococcus
saprophyticus is novobiocin resistant)

• Correct answer: A
• This patient has a Staphylococcus
epidermidis infection causing prosthetic
valve endocarditis
• Coagulase-negative staphylococcus on
gram stain
• The patient has a fever, heart murmur,
recent aortic valve replacement,
and a positive blood culture →
prosthetic valve endocarditis caused by
Staphylococcus epidermidis
76

Section 17 - Staphylococcus saprophyticus

1. Sap: Staphylococcus saprophyticus
2. Purple shirt: gram positive
3. Young attractive girl near urine: UTI in sexually
active women
4. Bison and chain: novobiocin resistant
5. Cat: catalase positive
6. Urine: urease positive
7. Flowers covered in urine: normal flora of the female
genital tract
8. Fury toes: nitrofurantoin is a first line agent for
uncomplicated UTIs
9. Meth crystals in sap: TMP-SMX is an effective
treatment
 77

REVIEW QUESTIONS ?
1. A 19-year-old sexually active female presents to
the office with dysuria, urgency, and frequency.
Urine cultures reveal gram-positive cocci.
What two lab tests would be most helpful in
distinguishing the causal organism from other
members of the genus?
A. The catalase test and the urease test
B. The catalase test and the type of hemolysis
observed on blood agar
C. The type of hemolysis observed on blood
agar and the coagulase test
D. The coagulase test and the catalase test
E. The coagulase test and the novobiocin test

• Correct answer: E
• This patient has a UTI caused by
Staphylococcus saprophyticus
• Dysuria, urgency, and frequency → UTI
• Young, sexually active, and urine
cultures have revealed gram-positive
cocci → Staphylococcus saprophyticus
• Staphylococcus saprophyticus,
Staphylococcus aureus, and
Staphylococcus epidermidis belong
to the same genus and can be
distinguished from each other using the
coagulase test and the novobiocin test
• See picture below (A, B, C, & D)
78
Section 18 - Nocardia
1. Notecards: Nocardia
2. Purple colors: gram positive
3. Tangled up cords: branching filamentous
morphology
4. Dirt: endemic in soil
5. Inhaler: obligate aerobe
6. Microphone: mycolic acid
7. Acid melting door rapidly: weakly acid-fast
8. Car bomb: carbol fuchsin
9. Urine: urease positive
10. Cat: catalase positive
11. Stretcher: predominantly occurs in
immunocompromised individuals
12. Burned skin: cutaneous involvement
13. Cough: pneumonia
14. Burning red car parts on top of the building: brain
abscesses
15. Meth crystals: treat with TMP-SMX
 79

REVIEW QUESTIONS ?
1. A 33-year-old homeless male is brought to
the emergency department due to a severe
headache and altered mental status. He has a
history of HIV and has not been compliant with
his medications. The patient also has had a
fever, night sweats, and a productive cough for
the past several weeks. Physical examination
reveals bilateral papilledema and crackles heard
throughout all lung fields. An MRI of the brain
reveals an abscess. Which of the following is
Photo Credit: CDC/Dr. Lucille K. George, Courtesy: Public Health Image Library true regarding the most likely causal organism?
Figure 5.2.36 - Gram stain of Nocardia A. It is a gram positive coccus
B. It is a gram negative rod
C. It is catalase positive
D. It is an obligate anaerobe

• Correct answer: C
• This patient has a brain abscess caused by
Nocardia
• Immunocompromised
• Noncompliant with medications
• Fever
• Night sweats
• Cough
Photo Credit: CDC/Dr. George P. Kubica [Public domain], via Wikimedia • Brain abscess
Commons • Nocardia is catalase positive
Figure 5.2.37 - Acid-fast stain of Mycobacterium • A is false because while Staphylococcus
Tuberculosis (similar to Nocardia) aureus is a more common cause of brain
abscess, the patient’s other symptoms (eg,
history of HIV, cough) make Nocardia more
likely
• B is false because Nocardia is a filamentous,
gram-positive rod
• D is false because Nocardia is an obligate
aerobe
80
Section 19 - Actinomyces israelii
1. Actor: Actinomyces israelii
2. Purple colors: gram positive
3. Tangled up cords: branching filamentous
morphology
4. Mask: anaerobic
5. Yellow sand in air: yellow “sulfur” granules
6. Flowers: part of the normal oral, reproductive, and
GI flora
7. Skull with open mouth: colonizes the mouth, is
found in dental caries, and can cause cervicofacial
disease
8. Movie director guy aspirating coffee: pulmonary
actinomyces may develop following aspiration
9. Devices: intrauterine device infection can result in
PID
10. Pennies: treat with penicillin
 81

REVIEW QUESTIONS ?
1. A 42-year-old female comes to the office due to
a chronic, slowly progressive, indurated mass
on the left side of her face. Physical examination
reveals a nontender mass near the left aspect of
the mandible. An aspiration of the mass is sent
for further analysis and a gram stain is shown
below.

Photo Credit: Yale Rosen from USA [CC BY-SA 2.0 https://creativecommons.
org/licenses/by-sa/2.0)]
Figure 5.2.38 - Gram stain of Actinomyces

Photo Credit: Yale Rosen from USA [CC BY-SA 2.0 https://
creativecommons.org/licenses/by-sa/2.0)]

A. It should be urgently treated with surgery

B. It is caused by an aerobic organism
C. The causal organism is part of the normal
oral flora
D. It stains weakly acid fast

Photo Credit: Yale Rosen from USA [CC BY-SA 2.0 https://creativecommons.
• Correct answer: C
org/licenses/by-sa/2.0)] • This patient has a cervicofacial abscess
Figure 5.2.39 - Sulfur granule caused by Actinomyces israelii
• Cervicofacial abscess affecting the
mandible is likely Actinomyces israelii
which comes from normal oral flora
• The gram stain shows a gram-positive
organism with a central sulfur granule
which is characteristic of Actinomyces
israelii
• A is false because the description of her
infection wouldn’t require urgent surgery
• B is false because Actinomyces israelii is an
anaerobic species
• D is false because Actinomyces israelii
doesn’t stain weakly acid-fast (Nocardia
does)
 82

Section 20 - Neisseria overview

1. Knife: Neisseria 10. Glue: ferments glucose

2. Pink colors: gram negative 11. Oompa loompas: opa-proteins
3. Two pieces of candy being dipped into the chocolate 12. “OPEN 9-5” sign: C5-C9 complement deficiency
bowl: diplococci increases susceptibility to recurrent neisseria
4. Prominent tall hat: Neisseria meningitidis infections
5. Gondola: Neisseria gonorrhoeae 13. Blue necklace: oxidase positive
6. Chocolate candy in chocolate factory: grows on 14. Thayer-Martin chocolate food van: grows in Thayer-
chocolate agar Martin agar
7. Lips: contains lipooligosaccharides (strong 15. Van: vancomycin is present in Thayer-Martin agar
endotoxins) 16. Nice Satan: nystatin is present in Thayer-Martin agar
8. Pillars and packages of various shapes and sizes: 17. Mixer: polymyxin is present in Thayer-Martin agar
displays antigenic variation of pili 18. Meth candy bar with three segments:
9. Scissors: IgA protease trimethoprim  is present in Thayer-Martin agar

Photo Credit: Content Provider(s): CDC/Dr. Norman Jacobs [Public domain], Photo Credit: CDC/Megan Mathias and J. Todd Parker [Public domain], via
via Wikimedia Commons Wikimedia Commons
Figure 5.2.40 - Gram stain of Neisseria Figure 5.2.41 - Chocolate agar
 83

Photo Credit: Jeff Dahl [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0 (https://creative commons.org/licenses/by-sa/4.0)], from Wikimedia
Commons
Figure 5.2.42 - Gram negative bacterial cell wall
REVIEW QUESTIONS ?
1. A 26-year-old male presents to the office due
to urethral discharge. One of his partners was
recently diagnosed with a sexually transmitted
infection. A swab of the discharge is sent for
further laboratory analysis. The pathologist
cultures the sample on a selective medium in an
attempt to isolate the causal organism. Which of
the following compounds is likely present in the
medium?
Photo Credit: http://commons.wikimedia.org/wikiFile: Cytoxydase.
jpg#filehistory A. Cephalexin
Figure 5.2.43 - Oxidase test B. Penicillin
C. Azithromycin
D. Vancomycin
E. Caspofungin

• Correct answer: D
• The patient presentation is suggestive of a
Neisseria gonorrhoeae infection
• A selective medium (which isolates
a particular organism) for Neisseria
gonorrhoeae is the Thayer-Martin agar
• Thayer-Martin agar contains
vancomycin, nystatin, polymyxin, and
Photo Credit: https://commons.wikimedia.org/wiki/File:Neisseria_ trimethoprim
gonorrhoeae_01.png
• A, B, C, and E are false because they are not
Figure 5.2.44 - Chocolate agar and Thayer-Martin
present in Thayer-Martin agar
agar
84
Section 21 - Neisseria meningitidis
1. Knife and top hat: Neisseria meningitidis
2. Pink colors: gram negative
3. Picture of Neisseria overview image: don’t forget
the overview information
4. Mist: transmitted through respiratory secretions
5. Sack: polysaccharide capsule
6. Syringe next to ammo sacks: the vaccine contains
antigens from the polysaccharide capsule
7. Horse with prominent nostrils: colonizes the nares
8. Malt beer: maltose fermenter
9. Sipping: sepsis
10. Red spots on horse: petechial rash
11. Hats: meningitis
12. Black foot and toes: gangrene of the toes
13. Putting fire out with a bucket of water: Waterhouse-
Friderichsen syndrome
14. Chimney shaped like a triangle: Waterhouse-
Friderichsen syndrome causes adrenal insufficiency
15. Lamp next to house: Waterhouse-Friderichsen
syndrome is associated with a fever
16. Coagulated jello: Waterhouse-Friderichsen
syndrome is associated with DIC
17. Stray wire and shock symbol: Waterhouse-
Friderichsen syndrome is associated with shock
18. Union soldier stabbing guy in the spleen: asplenic
patients are at an increased risk of developing an
infection
19. Pennies: treat with penicillin G
20. Trident: treat with ceftriaxone
21. Rifles with bayonets for close combat: close
contacts are prophylactically treated with rifampin
 85

REVIEW QUESTIONS ?
1. A 45-year-old female is brought to the
emergency department due to fever, a petechial
rash, and altered mental status. Her past
medical history is significant for an ATV accident
in which she sustained trauma to the abdomen
that required surgery due to internal bleeding.
Her blood pressure is 72/41 and heart rate is
129/min. Gram stain from a lumbar puncture
reveals gram-negative diplococci. Impairment of
which of the following most likely contributed
to this patient’s condition?
A. Reactive oxygen species
B. Immunoglobulin production
C. Complement production
D. Microtubule formation

• Correct answer: B
• The patient has a history of abdominal
trauma with significant internal bleeding
that required surgery - this suggests she had
a splenectomy following splenic rupture
• Her current presentation is suggestive of
Waterhouse-Friderichsen syndrome from an
infection with Neisseria meningitidis
• The absence of a spleen makes infection
from encapsulated organisms more
likely (Neisseria meningitis has a
polysaccharide capsule)
• The splenic B-lymphocytes produce
a large percentage of the body’s
immunoglobulins which help with
opsonization (IgG) and removal of
encapsulated organisms
• A is false because an inability to form
reactive oxygen species makes patients
more susceptible to catalase positive
organisms - as in NADPH deficiency
• C is false because the liver is where
complement proteins are produced
• D is false because microtubule dysfunction
is associated with drug effects
86
Section 22 - Neisseria gonorrhoeae
1. Gondola: Neisseria gonorrhoeae
2. Pink colors: gram negative
3. Neisseria overview image: don’t forget the overview
information
4. Unique pillars: antigenic variation of pili (evades
immune system and has prevented vaccine
development)
5. Scarlet letter: sexually transmitted infection
6. Peeing off ledge: dysuria and penile discharge in
males
7. Pee hitting eye: neonatal conjunctivitis
8. Fist: Fitz-Hugh-Curtis syndrome
9. Pregnant woman outside of the gondola: increased
risk of ectopic pregnancy
10. Uterus-looking chandelier: pelvic inflammatory
disease
11. Tendons about to burst: tenosynovitis
12. Glass breaking around knees: septic arthritis
13. Clam: chlamydial coinfection
14. Gnat bugs: diagnosis made with nucleic acid
amplification test (NAAT)
15. Trident: treated with ceftriaxone
16. Scarecrow: treated with macrolides (for chlamydial
coinfection)
 87

REVIEW QUESTIONS ?
1. A 24-year-old male presents to the clinic due
to dysuria. He states that his symptoms began
two days ago. He is sexually active with multiple
partners. Physical examination reveals a white
discharge expressed from the penis. Gram
stain of the discharge reveals gram-negative
diplococci seen in the cytoplasm of neutrophils.
Which of the following is the recommended
treatment regimen for the causal organism?
A. Doxycycline and cephalexin
B. Ceftriaxone and tigecycline
C. Trimethoprim-sulfamethoxazole
D. Ceftriaxone and azithromycin
E. Penicillin and clavulanic acid

• Correct answer: D
• The patient has urethritis caused by
Neisseria gonorrhoeae
• Dysuria
• Multiple partners
• White discharge expressed from the
penis
• Gram stain showing gram-negative
diplococci in the cytoplasm of
neutrophils
• Effective treatment involves
using both ceftriaxone and
azithromycin  (ceftriaxone is used
to cover gonococcal infection and
azithromycin is used to cover a possible
chlamydia coinfection)
• A is incorrect because doxycycline
can be used to treat the possible
Chlamydia coinfection but cephalexin is
a 1st generation cephalosporin and not
commonly used to treat STIs
• B is false because tigecycline is used
as a broad-spectrum antibiotic for
Staphylococcus aureus skin and soft tissue
infections as well as MRSA and VRE
• C and E are false because both
trimethoprim-sulfamethoxazole and
penicillin with clavulanic acid are not
used to treat Neisseria gonorrhoeae or
Chlamydia
88

Section 23 - Moraxella catarrhalis

1. Cactus: Moraxella catarrhalis 6. Colorado Police Department: COPD exacerbations

2. Red sunset: gram negative 7. Earmuffs on child: otitis media in children
3. Flowers on top of cacti: normal flora of the 8. Signs: sinusitis
respiratory tract 9. Ammo: amoxicillin is an effective treatment
4. Dusty mist: transmitted through respiratory droplets 10. Cleaver: an effective treatment is amoxicillin and
5. Inhaler: aerobe clavulanic acid
 89

REVIEW QUESTIONS ?
1. A 16-month-old boy is brought to the physician
due to increased irritability, fever, and poor
feeding. Physical examination reveals an
erythematous bulging tympanic membrane.
Which of the following is the most likely causal
organism?
A. Moraxella catarrhalis
B. Streptococcus pneumoniae
C. Haemophilus influenzae
D. Staphylococcus aureus
Photo Credit: CDC/Dr. W.A. Clark, Courtesy: Public Health Image Library
Figure 5.2.45 - Gram stain of Moraxella • Correct answer: B
• Streptococcus pneumoniae is the most
common cause of otitis media in children
(approximately 50% of cases)
• Moraxella catarrhalis accounts for less than
10% of cases (A)
• Haemophilus influenzae accounts for about
45% of cases (C)
• Staphylococcus aureus is a rare cause of
otitis media in children (D)

Photo Credit: Welleschik [GFDL (http://www.gnu.org/copyleft/fdl.html),

CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0) or CC BY-SA
2.5 (https://creativecommons/org/licenses/by-sa/2.5)], from Wikimedia
Commons
Figure 5.2.46 - Otoscopic view of otitis media
 90
Section 24 - Haemophilus influenzae
1. Office: Haemophilus influenzae
2. Pink walls: gram negative
3. Scissors: IgA protease
4. Jar of chocolate: grows on chocolate agar
5. Staff: can be grown near Staphylococcus aureus on
blood agar
6. Star fish with five points: factor V is necessary for
the growth of Haemophilus influenzae
7. “10 RULES OF THE OFFICE” sign: factor X is
necessary for the growth of Haemophilus influenzae
8. “PLEASE RESPECT PROPERTY” sign and stapler
surrounded by jello: encapsulated strains have a
polyribosylribitol phosphate (PRP) polysaccharide
capsule
9. Tape dividing the room in half: there are typeable
and nontypeable strains of Haemophilus influenzae
10. Syringe: there is a vaccine for Haemophilus
influenzae serotype b (Hib)
11. Dwayne opening mouth and yelling “Michael”:
Haemophilus influenzae serotype b (Hib) causes
epiglottitis
12. Computer screen that has the “thumb sign”:
“thumb sign” seen on lateral neck x-ray
13. Michael with red knees: Haemophilus influenzae
serotype b (Hib) causes septic arthritis
14. Hood: Haemophilus influenzae serotype b (Hib)
causes meningitis
15. Sickle: asplenia increases the risk of Haemophilus
influenzae serotype b (Hib)  infections
16. Trident: ceftriaxone can be used to treat
Haemophilus influenzae serotype b (Hib) infections
17. Rifle on shirt: rifampin prophylaxis for close contacts
18. Broken keyboard: nontypeable strains (not
encapsulated)
19. Smoke: aerosolized transmission
20. Signs: nontypeable strains of Haemophilus
influenzae cause sinusitis
21. Ear muffs: nontypeable strains of Haemophilus
influenzae cause acute otitis media
22. Red eyes: nontypeable strains of Haemophilus
influenzae cause conjunctivitis
23. Ammo and a cleaver: nontypeable strains of
Haemophilus influenzae are treated with amoxicillin
and clavulanate
 91

Photo Credit: Dimitrios Malamos [CC BY 4.0 (https://creativecommons.org/

licenses/by/4.0)]
Figure 5.2.49 - Epiglottis
Photo Credit: Bobjgalindo [GFDL (http://www.gnu.org/copyleft/fdl.html)
or C BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from
Wikimedia Commons
Figure 5.2.47 - Gram Stain of Haemophilus
influenzae

Photo Credit: Deminorwood [CC BY-SA 4.0 (https://creativecommons.org/

licenses/by-sa/4.0)]
Figure 5.2.48 - Satellite colonies of Haemophilus
influenzae growing near Staphylococcus aureus on
blood agar
 92

Photo Credit: [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-

sa/3.0)]
Figure 5.2.51 - Cherry red epiglottis

Photo credit: Med Chaos [CC0]

Figure 5.2.50 - Thumb sign
 93

REVIEW QUESTIONS ?
1. A researcher is studying an organism that
demonstrates poor growth on 5% sheep
blood agar. However, the same organism
grows well when incubated next to colonies of
Staphylococcus aureus. The organism described
is known to cause invasive disease through the
use of what virulence factor?
A. M protein
B. Polyribosylribitol phosphate
C. Erythrogenic exotoxin A
D. Pyrrolidonyl arylamidase

• Correct answer: B
• The organism being described is
Haemophilus influenzae
• Demonstrates poor growth on 5% sheep
blood agar but grows well when grown
next to colonies of Staphylococcus
aureus
• Staphylococcus aureus is β-hemolytic
so it lyses red blood cells and provides
nearby colonies of Haemophilus
influenzae with NAD (factor V) and
hematin (factor X)
• The encapsulated strains of
Haemophilus influenzae bacterium
have a polyribosylribitol phosphate
polysaccharide capsule
• A is incorrect because M protein is
a virulence factor associated with
Streptococcus pyogenes (β-hemolytic and
would grow well on blood agar)
• C is incorrect because the erythrogenic
exotoxin A is also associated with
Streptococcus pyogenes and results in shock
after it stimulates an overwhelming release
of cytokines
• D is false because pyrrolidonyl arylamidase
(known as PYR) is associated with
Streptococcus pyogenes and Enterococcus
and is not a virulence factor
94

Section 25 - Bordetella pertussis

1. Border: Bordetella pertussis 11. Catapult: catarrhal stage

2. Pink colors: gram negative 12. Guy coughing due to smoke: a mild cough is
3. Boards blocking entrance: Bordet-Gengou agar commonly seen during the catarrhal stage
4. Rays: Regan-Lowe medium 13. Lamp: a fever is commonly seen during the
5. G.I. Joe guy falling down with an arrow stuck in catarrhal stage
chest: the pertussis toxin disables the G subunit
i 14. Watery eyes next to onions: coryza is commonly
6. Camping tent: ribosylation of the G subunit
i seen during the catarrhal stage
results in increased levels of cAMP 15. Rocks: paroxysmal stage
7. Another camping tent: adenylate cyclase toxin 16. Dust and severe coughing: severe coughing spells
increases levels of cAMP (paroxysmal cough) are commonly seen during
8. Tray and toxic gas: tracheal cytotoxin (damages the paroxysmal stage
respiratory epithelial cells) 17. Vomiting after coughing: post tussive vomiting may
9. Rope pulling catapult: filamentous hemagglutinin be seen during the paroxysmal stage
(FHA) facilitates the attachment of the pathogen 18. Convicts: convalescent stage
to ciliated epithelial cells 19. Zipper: treat with azithromycin
10. Spherical rocks with a purple hue: causes a 20. Syringe: vaccine (DTaP and Tdap) given to prevent
lymphocytosis infection
 95

REVIEW QUESTIONS ?
1. A 2-year-old unvaccinated boy is brought to
the emergency department due to difficulty
breathing. His mother states that she first
noticed his symptoms approximately two weeks
ago which included a mild cough, a runny
nose, and intermittent sneezing. Recently the
cough has become so severe that he has had
trouble breathing and has vomited several
times afterward. Physical examination reveals
episodes of severe coughing spells followed by
a forced expiratory grunt. Laboratory analysis
reveals a lymphocytosis. The most likely causal
organism produces a toxin that:
A. Inactivates the 60S ribosome
B. Increases the activity of guanylate cyclase
C. Increases the activity of adenylate cyclase
Photo Credit: CDC Public Health Image Library [Public domain] D. Inactivates elongation factor 2
Figure 5.2.52 - Gram stain of Bordetella
• Correct answer: C
• This patient has a Bordetella pertussis
infection
• Difficulty breathing
• Cough
• Coryza
• Posttussive emesis
• Lymphocytosis
• The pertussis toxin over activates
adenylate cyclase by disabling G which
i

results in increased levels of cyclic AMP

• A is false because inactivation of the 60S
ribosome is indicative of Shiga toxin and
Shiga-like toxin from Shigella and E. coli
• B is false because it is the heat-stable toxin
of E. coli that increases the activity of
guanylate cyclase
• D is false because the toxins that inactivate
Photo Credit: https://www.flickr.com/photos/54976525@N08/5905471297 elongation factor 2 are the diphtheria toxin
Figure 5.2.53 - Regan-Lowe agar of Corynebacterium diphtheriae and the
exotoxin A of Pseudomonas aeruginosa
96
Section 26 - Pasteurella multocida, Brucella spp., and Francisella tularensis
1. Bruce Wayne: Brucella
2. Eiffel tower: Francisella tularensis
3. Pastor: Pasteurella multocida
4. Pink colors: gram negative
5. Ejecting out of batmobile: Brucella species are
facultative intracellular organisms
6. Rolling hills: Brucella is associated with an undulant
fever
7. Fresh farmer’s market booth and milk: Brucella is
associated with ingestion of unpasteurized dairy
8. Dirt bike: Brucella is treated with doxycycline
9. Rabbit: rabbits are reservoirs for Francisella
10. Tic tacs: ticks are a common reservoir for Francisella
11. Pavilion: Francisella is facultative intracellular
12. Joker cutting granny’s arm: Francisella causes
painful skin lesions
13. Hand on head as if hot and sweating: Francisella
causes a fever
14. Granny: Francisella is associated with granuloma
formation
15. Flies: deer flies are reservoirs for Francisella
16. Minnow fish: Francisella is treated with
aminoglycosides
17. Pastor with blue necklace: Pasteurella is oxidase
positive
18. Sack of bibles: Pasteurella has a polysaccharide
capsule
19. Cat: Pasteurella is catalase positive
20. Dog biting pastor: Pasteurella is transmitted through
dog bites
21. Blood from bite wound: Pasteurella grows on 5%
blood agar
22. Wound on arm: Pasteurella is associated with
animal bites and skin infections
23. Fish bones and scales: Pasteurella causes
osteomyelitis
24. Penny: Pasteurella is treated with penicillin
 97

REVIEW QUESTIONS ?
1. A 32-year-old female comes to the office due
to a red swollen arm. She recently purchased
an extremely hyper dog that bit her on the arm
last night as they were playing. Immediately
after the injury she felt fine so she went to sleep
without much concern. However, when she
woke up this morning she noticed the swelling
and decided to come to the office. Physical
examination is significant for an edematous and
erythematous wound on the left arm that is
tender to palpation. Cultures of the wound grow
gram-negative coccobacilli that are catalase-
positive. Which of the following is the definitive
treatment for the most likely causal organism?
A. Daptomycin
Photo credit: CDC [Public domain]
B. Doxycycline
Figure 5.2.54 - Gram stain of gram-negative C. Gentamicin
coccobacilli D. Penicillin

• Correct answer: D
• The patient has a Pasteurella infection
• Recent dog bite
• Culture of the wound shows gram-
negative coccobacilli that are catalase-
positive
• Standard treatment for Pasteurella is
penicillin
• A is false because daptomycin is commonly
used to treat skin infections (MRSA),
bacteremia, endocarditis, and VRE
• B is false because Brucella is often treated
with doxycycline but the commonly seen
Photo Credit: Sanjay Mukhopadhyay [Public domain], via Wikimedia
symptoms of undulant fever and weight
Commons loss, as well as a history of drinking
Figure 5.2.55 - Granuloma unpasteurized milk are absent
• C is false because gentamicin is used to treat
Francisella tularensis
 98
Section 27 - Salmonella spp.
1. Salmon: Salmonella
2. Red and pink colors: gram negative
3. Flag: flagellated
4. Fish surrounded by a net: encapsulated
5. Trail of blood: spreads hematogenously
6. Pink bubbles that resemble neutrophils:
polymorphonuclear neutrophils (PMNs) are seen in
disseminated disease
7. Black cloud: hydrogen sulfide production on TSI agar
8. Meat and eggs: eggs and meat (poultry) are
reservoirs
9. Turtle: turtles are reservoirs
10. Raspberry patch: invades the gastrointestinal tract
through M cells (found in Peyer’s patches)
11. Pavilion: facultative intracellular
12. Lemons: acid-labile (large inoculum required)
13. Guy writing: may cause Reiter syndrome (reactive
arthritis)
14. Vomiting: causes vomiting
15. Bloody water: causes bloody diarrhea
16. Three guys secreting the vomit: utilizes a type III
secretion system
17. Toxic smoke cloud: one of the virulence factors of
Salmonella is an endotoxin
18. Fish with prominent scales: causes osteomyelitis in
patients with sickle cell disease
19. Trident: treat sickle cell osteomyelitis with
ceftriaxone
20. “DO NOT PASS” sign: do not give antibiotics to
patients with GI-related Salmonella infections
 99

REVIEW QUESTIONS
1. A 17-year-old female presents to the emergency
Photo Credit: Roinujus [CC BY-SA 4.0 (https://creaivecommons.org/licenses/
by-sa/4.0)]
Figure 5.2.56 - Gram stain of Salmonella
?
department with a 4-hour history of nausea,
vomiting, and diffuse abdominal pain. She
also states that she has had several loose
bowel movements and one appeared slightly
red. Physical examination is significant for
diffuse abdominal pain and a fever of 38.7°C. A
stool sample is obtained and reveals oxidase-
negative, nonlactose-fermenting organisms
that produce a black color when placed in
TSI agar. Treating the patient’s condition with
ciprofloxacin would most likely result in:
A. Rapid improvement of the patient’s
condition
B. Infertility
C. An increased duration of bacterial fecal
excretion
D. Hepatosplenomegaly
E. Osteomyelitis

• Correct answer: C
• The patient has gastroenteritis caused by
Salmonella
• Nausea, vomiting, and diffuse
abdominal pain → gastroenteritis
• Bloody diarrhea, oxidase-negative,
nonlactose-fermenting, and black color
on TSI agar → Salmonella
• Treatment of Salmonella gastroenteritis
with ciprofloxacin would increase
Photo credit: Witmadrid [Public domain]
the duration of the illness and an
Figure 5.2.57 - TSI agar increased duration of bacterial fecal
excretion would be seen (Salmonella
gastroenteritis is usually self-limiting)
• A is false because antibiotic treatment of
Salmonella gastroenteritis is considered
ineffective with respect to the duration of
the illness
• B and D are false because infertility and
hepatosplenomegaly are not known side
effects of ciprofloxacin (which can be toxic
to the liver but does not affect the spleen)
• E is false because osteomyelitis is a
complication of Salmonella infection
especially in patients with sickle cell disease
who have areas of infarction and necrosis in
Photo Credit: User:Plainpaper [CC BY-SA 3.0 (https://creativecommons.org/ certain bone and bone marrow locations
licenses/by-sa/3.0)]
Figure 5.2.58 - Peyer’s patches
100
Section 28 - Salmonella typhi
1. Thai restaurant: Salmonella typhi
2. Pink colors: gram negative
3. Flag: flagellated
4. Black smoke rising from eggs: hydrogen sulfide
production on TSI agar
5. Green smoke: one of the virulence factors of
Salmonella typhi is an endotoxin
6. Hiker guy: associated with a history of traveling
7. Sleep sack: has a Vi polysaccharide capsule
8. Lemons: acid-labile (large) inoculum required
9. Balloon that resembles a monocyte: immune
response is primarily monocytes
10. Banana trees: can colonize the gallbladder in a
chronic carrier state
11. Lamp: typhoid fever causes a fever
12. Blood stains: typhoid fever causes a rash
characterized by rose spots on the abdomen
13. Guy sitting on toilet next to muddy brown river:
typhoid fever causes abdominal pain, constipation,
and diarrhea
14. Smelling flowers next to “LIVE FISH” sign: live
attenuated vaccine
15. Syringe injecting juice into fish and juice spraying on
sleep sack: the IM vaccine contains the Vi antigen
from the polysaccharide capsule
16. Flower staff: treat with fluoroquinolones
17. Trident: treat with ceftriaxone
 101

REVIEW QUESTIONS ?
1. A 27-year-old male comes to the clinic due to
fever, abdominal pain, and diarrhea. He first
noticed the symptoms one week ago after
returning from a humanitarian trip to Nepal.
Physical examination reveals a temperature of
38.5°C, an erythematous maculopapular rash on
his abdomen, and diffuse abdominal tenderness
upon palpation. Blood and stool cultures are
pending. This patient is most likely at risk of
developing:
Photo Credit: Content Provider(s): CDC/Armed Forces Institute of Pathology,
Charles N. Farmer [Public domain] A. Continued fecal bacterial shedding
Figure 5.2.59 - Rose spots B. Rapid resolution of his symptoms without
antibiotic administration
C. Worsening of the rash which may involve
the hands and palms
D. Hemolytic uremic syndrome

• Correct answer: A
• The patient has an infection caused by
Salmonella typhi
• Fever, abdominal pain, diarrhea, recent
travel history to an endemic area, and
erythematous maculopapular rash on
his abdomen
• Patients who develop Salmonella typhi
are at risk of developing a chronic
carrier state of infection where the
bacteria colonize in the gallbladder →
continued fecal shedding of the bacteria
as proliferation continues without
treatment
• B is false because the rapid resolution
of symptoms without treatment is
characteristic of nontyphoidal Salmonella
species
• C is false because of the rash of Salmonella
typhi lasts for 10-14 days generally and is
commonly distributed on the chest, back,
and abdomen
• D is false because Shigella and E. coli
produce toxins that can cause HUS and
damage the kidneys
102
Section 29 - Shigella
1. Shit: Shigella
2. Red sunset: gram negative
3. Pooper scooper team of three: utilizes a type III
secretion system
4. Poop thrown from one person and landing on
another person: human-to-human transmission
only
5. Raspberry patches: invades the gastrointestinal
tract through M cells (found in Peyer’s patches)
6. Horse reins that resemble actin: manipulates the
host’s actin filaments which allows the organism to
move intracellularly
7. Hoof prints that resemble the nuclei of neutrophils:
immune response is primarily neutrophils
8. Stationary handcuffed guy: immotile (no flagella)
9. 60 minute news crew: Shiga toxin inhibits the 60S
ribosomal subunit
10. Coal covered in blood: enterohemorrhagic E. coli
(EHEC) has a toxin that closely resembles Shiga toxin
(Shiga-like toxin)
11. Orange juice being blocked: acid resistant (low
inoculum required)
12. Red candy on top of poop: Shiga toxin causes
damage to the GI mucosa resulting in dysentery and
bloody diarrhea
13. Tangled up strings that resemble the glomerulus
and red balloons: Shiga toxin causes hemolytic
uremic syndrome
14. Guy writing: may cause Reiter syndrome (reactive
arthritis)
15. Shit and disco ball: Shigella dysenteriae (most
severe)
16. Flexing guy: Shigella flexneri (2nd most severe)
17. Body builder guy: Shigella boydii (3rd most severe)
18. Body builder’s son: Shigella sonnei (4th most
severe)
19. Amp: treated with ampicillin
20. Flower staff: treated with fluoroquinolones
21. Meth crystals: treated with TMP-SMX
22. Trident: treated with ceftriaxone
 103

Photo Credit: Paulo Henrique Orlandi Mourao [CC BY-SA 3.0 (https://
creativecommons.org/licenses/by-sa/3.0)]
Figure 5.2.63 - Schistocytes

REVIEW QUESTIONS ?
1. A 12-year-old girl is brought to the emergency
Photo Credit: CDC/Armed Forces Institute of Pathology (AFIP) department due to bloody diarrhea which
Figure 5.2.60 - Gram stain of Shigella began 2 days ago. Stool cultures grow non-
lactose fermenting gram-negative bacilli that
do not produce hydrogen sulfide when grown
on triple sugar iron agar. It is determined that
her infection is caused by an extremely invasive
organism that can cause disease with exposure
to as few as 10 organisms. The pathogenesis of
this patient’s condition is most likely caused by:
A. Hematogenous spread
B. Invasion of cells that overlie intestinal
lymphatic aggregates
C. Aerosolized inhalation
Photo Credit: Jeff16 [CC BY-SA 4.0 (https://creativecommons.org/licenses/
D. Excess proliferation of normal bacterial flora
by-sa/4.0)] E. Spore germination
Figure 5.2.61 - Actin
• Correct answer: B
• This patient has an infection caused by
Shigella
• Bloody diarrhea
• Stool cultures that grow non-lactose
fermenting gram-negative bacilli that do
not produce HS on triple sugar iron agar
• A very low inoculum is required for
Shigella to cause disease
• Shigella infects M cells which overlie the
intestinal lymphatic aggregates (Peyer’s
patches)
• A is false because Shigella spreads from cell
to cell - not hematogenously
Photo Credit: Dr. Graham Beards [CC BY-SA 3.0 (https://creativecommons. • C is false because Shigella infects after
org/licenses/by-sa/3.0)] ingestion into the GI tract
Figure 5.2.62 - Neutrophils • D is false because Shigella doesn’t form part
of the normal GI flora
• E is false because Shigella isn’t spore-
forming
104
Section 30 - E. coli
1. Coal mine: Escherichia coli (E. coli)
2. Pink reflection: gram negative
3. Bay: β-hemolytic
4. Flowers: normal flora of the colon
5. Green machine: green metallic sheen on eosin
methylene blue (EMB) agar
6. Monkey animal crackers: E. coli is a lactose
fermenter (pink color on MacConkey agar)
7. “Speed 50 MPH” sign: fast lactose fermenter
8. Cat: catalase positive
9. Dole whip: indole positive
10. Three guys helping carry water: utilizes a type III
secretion system
11. Guy with bacteria spontaneously growing over his
abdomen: causes spontaneous bacterial peritonitis
12. Pillar pipe on fire going to outhouse: E. coli has
virulent pili that are associated with UTIs, cystitis,
and pyelonephritis
13. Thin wires that resemble fimbriae: E. coli has
virulent fimbriae that are associated with cystitis
and pyelonephritis
14. Prostitute: causes prostatitis
15. Ammo near outhouse: amoxicillin can be used to
treat E. coli UTIs
16. Sack and letter “K” on hat: K antigen is present in
the polysaccharide capsule
17. Pregnant woman and hat: serotypes of E. coli
with the K antigen are commonly associated with
neonatal meningitis
18. Pregnant lady coughing: serotypes of E. coli with the
K antigen are commonly associated with pneumonia
19. Torch: a TORCHES infection
20. Lips, sack, sipping, and shock: has a
lipopolysaccharide virulence factor that causes
septic shock
21. Coal and blood: enterohemorrhagic E. coli (EHEC)
22. Pool of blood: EHEC causes bloody diarrhea
23. Microphone shaped like the number one: EHEC is
the most common serotype of E. coli in the United
States
24. Smashed cup of sorbet: EHEC does not ferment
sorbitol
25. Hamburger and green leafy lettuce: EHEC is
transmitted via undercooked meat and raw leafy
vegetables
26. O157:H7 written on shirt: O157:H7
27. Shit hitting 60 minutes camera: EHEC produces
shiga-like toxin that inhibits the 60S ribosomal
subunit
28. Shit, strings that resembles the glomerulus, and red
balloons: shiga-like toxin causes hemolytic-uremic
syndrome

29. Broken plate: shiga-like toxin causes
thrombocytopenia
30. Rock smashing balloon: hemolytic-uremic syndrome
causes mechanical hemolysis resulting in anemia
31. Helmet shaped like a schistocyte: shiga-like toxin
causes microthrombi formation --> schistocytes and
renal failure
32. Rock on fire and rock with black spots: shiga-like
toxin causes necrosis and inflammation
33. Rope pathway: enteropathogenic E. coli
34. Smashed plants that resemble intestinal villi:
enteropathogenic E. coli adheres to apical surfaces
of intestinal cells, flattens villi, and prevents
absorption
35. Child’s clothes covered in mud: enteropathogenic E.
coli causes diarrhea in children
36. Happy child with thumbs up on shirt:
enteropathogenic E. coli does not produce a toxin
37. Vase and coal: enteroinvasive E. coli
38. Shit falling: the clinical manifestations of
enteroinvasive E. coli are similar to Shigella
Photo Credit: Bobjgalindo [CC BY-SA 4.0(https://creativecommons.org/
licenses/by-sa/4.0)]
Figure 5.2.64 - Gram stain of E. coli
Photo Credit: Witmadrid [Public domain]
Figure 5.2.65 - Eosin methylene blue aga
105
39. Rock on fire and rock with black spots:
enteroinvasive E. coli invades the intestinal mucosa
and causes inflammation and necrosis
40. Toxic cloud: enterotoxigenic E. coli
41. Travelers: enterotoxigenic E. coli causes travelers’
diarrhea
42. Water: enterotoxigenic E. coli causes watery
diarrhea
43. Warm and stable guy: enterotoxigenic E. coli
produces a heat-stable enterotoxin
44. Heat generator near warm and stable guy: the heat-
stable enterotoxin increases levels of cGMP
45. Emotionally-labile guy crushed by a rock:
enterotoxigenic E. coli produces a heat-labile
enterotoxin
46. Camping tent near emotionally labile guy: the heat-
labile enterotoxin increases levels of cAMP
47. Fire getting put out by water: enterotoxigenic E. coli
does not cause inflammation or invasion
48. Travelers with prominent collars: enterotoxigenic E.
coli causes watery diarrhea that is similar to cholera
Photo Credit: Medimicro [Public domain]
Figure 5.2.66 - MacConkey agar
106

Photo Credit: Botolph [Public domain]

Photo Credit: Microrao [Public domain]
Figure 5.2.67 - Indole test Figure 5.2.68 - Lipopolysaccharide
 107

REVIEW QUESTIONS ?
1. A 22-year-old male presents to the emergency
department due to abdominal pain and
diarrhea that started yesterday. He states that
he recently ate an undercooked hamburger
from a restaurant and is worried he may have
developed an infection. Physical examination
is significant for diffuse abdominal tenderness
and guaiac-positive bloody stools. Stool cultures
reveal a gram-negative organism that is indole-
positive and does not ferment sorbitol on
sorbitol-containing MacConkey agar. Additional
laboratory analysis will most likely reveal which
of the following?
A. Thrombocytosis
B. Elevated serum creatinine and blood urea
nitrogen
C. Fragmented platelets on a peripheral blood
smear
D. A positive Coombs test

• Correct answer: B
• The patient has an infection by
enterohemorrhagic E. coli (EHEC)
• Guaiac-positive bloody diarrhea
• Does not ferment sorbitol
• EHEC can cause HUS because the
Shiga-like toxin causes microthrombi
formation and results in schistocytes
and kidney damage
• Kidney damage results in elevated
serum creatinine and blood urea
nitrogen
• A is false because E. coli does not cause
thrombocytopenia via platelet consumption
• C is false because the platelets are not
fragmented, the RBCs are (schistocytes)
• D is false because a positive Coombs test
indicates the presence of antibodies that
are causing RBC hemolysis which is not seen
in E. coli infections
108

Section 31 - Klebsiella

1. Club: Klebsiella 10. Molotov cocktail: associated with lobar pneumonia

2. Pink sunset: gram negative
3. Flowers next to dirty river: part of the normal
gastrointestinal flora
4. Fast monkey: ferments lactose on MacConkey agar
(fast lactose fermenter)
5. Sacks: polysaccharide capsule
6. Urine: urease positive
7. Spilled container of pills: associated with multidrug
resistance
8. Mucous: mucoid colonies
9. Dyed beads and guy coughing: associated with lobar
pneumonia in diabetics when aspirated
in alcoholics when aspirated
11. Strangled: may cause struvite kidney stones
12. Monkey eating liver: causes hepatic abscesses
13. Bacteria spontaneously growing on abdomen:
causes spontaneous bacterial peritonitis
14. Young attractive girl next to urine: causes urinary
tract infections
15. Red and green cubes of jello: classically associated
with red “currant jelly” sputum
16. Black river: lung abscesses and liquefactive necrosis
of lung tissue
 109

REVIEW QUESTIONS ?
1. A 53-year-old homeless male with a history
of alcoholism is brought to the emergency
department due to 3 days of chest pain,
chills, and shortness of breath. He quickly
destabilizes and passes away despite aggressive
intervention. A sputum culture obtained upon
admission to the emergency department
revealed gram-negative bacilli that formed
mucoid colonies. An autopsy revealed
Photo Credit: Microrao, JJMMC, Davangere, Kamataka, India [Public domain] the presence of lung abscesses filled with
Figure 5.2.69 - Mucoid colonies liquefactive necrosis. The organism most likely
responsible for this patient’s death:
A. Slowly produces a pink color on MacConkey
agar
B. Rapidly produces a pink color on
MacConkey agar
C. Slowly produces a yellow color on
MacConkey agar
D. Rapidly produces a yellow color on
MacConkey agar

• Correct answer: B
• The patient has aspiration pneumonia due
to Klebsiella
• History of alcoholism, chest pain,
Photo Credit: Doruk Salanci [CC BY-SA 3.0 (https://creativecommons.org/
and shortness of breath → aspiration
licenses/by-sa/3.0)] pneumonia
Figure 5.2.70 - Struvite crystals • Sputum culture shows gram-negative
bacilli that form mucoid colonies and
there are lung abscesses filled with
liquefactive necrosis → Klebsiella
infection
• Klebsiella is a fast lactose fermenter on
MacConkey agar (turns pink)
• A is false because Klebsiella is a fast lactose
fermenter
• C and D are false because Klebsiella is a
lactose fermenter and produces a pink color
when plated on MacConkey agar
110

Section 32 - Proteus mirabilis

1. Proteus god: Proteus mirabilis
2. Pink and red colors: gram negative
3. Flipper: exhibits swarming motility when plated
4. Urine: urease positive
5. Black smoke near eggs: hydrogen sulfide production
on TSI agar
6. Stones: kidney stones
7. Strangled: may cause struvite kidney stones
8. Horns: staghorn calculi may be seen
9. Water splashing on girl’s crotch: causes urinary tract
infections
10. Green stench cloud rising from fish: causes a distinct
fishy scent
11. Ammo: treated with amoxicillin
 111

REVIEW QUESTIONS ?
1. A 37-year-old male comes to the emergency
department because of a 3-hour history of
dysuria and hematuria. His temperature is
38.4°C, pulse is 112/min, and blood pressure is
158/84. Physical examination is significant for
left costovertebral angle tenderness. Urinalysis
reveals the presence of blood and a pH of 6.7
(normal: <5.3). An X-ray of the abdomen (KUB)
reveals the presence of a staghorn calculus in
the left kidney. This patient’s condition is most
likely caused by:
A. Dehydration
B. An organism that produces ammonia from
urea
C. High levels of uric acid
D. Impaired cystine reabsorption in the
proximal convoluted tubule

• Correct answer: B
• Patient has a kidney stone caused by
Proteus mirabilis
• Dysuria
Photo Credit: © Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/ • Hematuria
licenses/by-sa/3.0)]
• CVA tenderness
Figure 5.2.71 - Staghorn calculus • Staghorn calculus
• The urinalysis results of a pH of
6.7 indicates a struvite or calcium
phosphate kidney stone rather than uric
acid or cystine kidney stones (where a
low pH would be present)
• The staghorn calculus suggests infection
with an organism that produces
ammonia from urea - a urease positive
organism - like Proteus mirabilis
• A is false because it is referring to calcium
oxalate stones
• C is false because it is referring to uric acid
kidney stone
• D is false because it is referring to cystine
kidney stones
112
Section 33 - Pseudomonas aeruginosa
1. Painting of Mona Lisa: Pseudomonas aeruginosa
2. Pink color of the building: gram negative
3. Flag: flagellated (motile)
4. Statue of a cat: catalase positive
5. Three holes in the wall and robbers throwing down
stolen valuables: utilizes a type III secretion system
6. Stuffing valuables into a sack: polysaccharide
capsule
7. Woman wearing a blue necklace: oxidase positive
8. Panicked woman using inhaler: obligate aerobe
9. Scared woman who urinated: causes urinary tract
infections
10. Oblivious guard eating grapes: produces a grape-like
fruity odor
11. Modern art showing blue and green paint: produces
a blue-green pigment (pyocyanin and pyoverdin)
12. Exploding tank of oxygen near the blue and green
paint: pyoverdin and pyocyanin generate reactive
oxygen species
13. Officer from the “Agency” wielding an elongating
baton: exotoxin A inactivates elongation factor 2
(EF-2)
14. Clothespins hanging the “Come see” sign: produces
phospholipase C (a toxin that degrades cell
membranes)
15. Grenade releasing green smoke and causing an
electrical fire that shocks a burglar: produces an
endotoxin which causes shock
16. Flames burning the burglar: causes skin infections in
burn victims
17. Guard putting salt in the water softener is coughing
on grenade smoke: causes pneumonia (especially in
cystic fibrosis patients)
18. SWAT team with night-vision goggles: keratitis and
corneal ulcers (contact lens wearers)
19. Red and black bullet wound: causes ecthyma
gangrenosum (especially in immunocompromised
patients)
20. Special headset covering the ears: causes otitis
externa (swimmer’s ear)
21. Burglar with dyed beads in his hair: more common
in diabetics
22. Decorative fountain: causes hot tub folliculitis
23. Guard sipping a drink: causes sepsis
24. A nurse making things worse by running toward
an active robbery: associated with nosocomial
infections
25. Drug addict stealing medications from the
unattended ambulance: associated with drug
addicts
 113

26. Security guard with scaly bullet-proof vest: causes 29. Pine tree car freshener: treated with cefepime
osteomyelitis 30. Leaky pipe: treated with piperacillin
27. Getaway car: causes endocarditis 31. Minnows swimming in the fountain: treated with
28. Robber offering flowers: treated with aminoglycosides
fluoroquinolones 32. Tiger painting on the wall: treated with ticarcillin

Photo Credit: CDC [Public domain]

Figure 5.2.72 - Gram stain of Pseudomonas

Photo Credit: James Hellman, MD [CC BY-SA 3.0 (https://creativecommons.

org/licenses/by-sa/3.0)]
Figure 5.2.74 - Corneal abrasion

Photo Credit: Y tambe [CC BY-SA 3.0 (http://creativecommons.org/licenses/

by-sa/3.0)]
Figure 5.2.73 - Pyoverdin and pyocyanin (bluish-
green color) of Pseudomonas (left)
114

Photo Credit: James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.

org/licenses/by-sa/3.0)]
Figure 5.2.76 - Hot tub folliculitis

Photo Credit: James Heilman, MD [CC BY 3.0 (https://creativecommons.org/

licenses/by/3.0)]
Figure 5.2.75 - Otitis externa
 115

REVIEW QUESTIONS ?
1. A 24-year-old female is admitted to the
hospital following a house fire in which she
sustained third-degree burns over her trunk
and arms. Several days after aggressive
fluid administration, pain management, and
surgical debridement she develops a diffuse
skin infection. She is successfully treated with
cefepime and tobramycin and discharged
from the hospital. The organism most likely
responsible for this patient’s skin infection is:
A. Oxidase negative
B. Urease positive
C. Motile
D. A slow lactose fermenter

• Correct answer: C
• This patient has an infection by
Pseudomonas aeruginosa
• Burn victim
• Developed a diffuse skin infection
• Treated successfully with cefepime and
tobramycin
• Pseudomonas aeruginosa is a
flagellated motile organism
• A, B, and D are not characteristic of
Pseudomonas aeruginosa which is oxidase
positive, urease negative, and does not
ferment lactose
116
Section 34 - Yersinia pestis and enterocolitica
1. Yerba mate: Yersinia pestis
2. “DO NOT ENTER” sign: Yersinia enterocolitica
3. Pink sunset: gram negative
4. Sacks of yerba mate: encapsulated
5. Outdoors but also has shelter from a large canopy:
facultative intracellular
6. Fleas, rats, and prairie dogs roaming the alley:
Yersinia pestis is transmitted through rats, prairie
dogs, and fleas
7. Plague doctor mask: Yersinia pestis causes the
bubonic plague
8. Man with bleeding armpits: Yersinia pestis causes
buboes (erythematous, swollen, and painful lymph
nodes)
9. Sacks of food for those in need: Yersinia
enterocolitica is encapsulated
10. Pork and milk: Yersinia enterocolitica is transmitted
through contaminated milk and pork
11. Dog pooping into the sewer: Yersinia enterocolitica
is transmitted through pet feces
12. Fancy pen: Yersinia enterocolitica causes
pseudoappendicitis
13. Writing on a notepad: Yersinia enterocolitica causes
Reiter syndrome
14. Vomiting: Yersinia enterocolitica causes vomiting
and diarrhea
15. Flower staff: Yersinia pestis and Yersinia
enterocolitica can be treated with fluoroquinolones

REVIEW QUESTIONS
1. A 27-year-old male presents to the emergency
Photo Credit: CDC [Public domain]
Figure 5.2.77 - Gram stain gram of Yersinia
enterocolitica
Photo Credit: CDC [Public domain]
Figure 5.2.78 - Axillary Bubo
117
?
department while on vacation in California due
to a fever, chills, and axillary pain. Additional
history reveals that while driving through
Nevada he accidentally ran over a rodent.
He was very distressed by the situation so
he spent 30 minutes burying it on the side of
the road. Physical examination reveals tender
lymphadenopathy in the left axilla. A sample
of fluid from the lymph node reveals gram-
negative bacilli. This patient’s condition is most
likely caused by:
A. Coccidioides immitis
B. Yersinia pestis
C. Blastomyces dermatitidis
D. Yersinia enterocolitica
E. Cryptococcus neoformans
• Correct answer: B
• This patient has a Yersinia pestis infection
• Rodent exposure
• Tender lymphadenopathy in left axilla
(buboes)
• Gram-negative bacilli
• A is incorrect due to the lymphadenopathy
although it is found in the same U.S. region
• C is incorrect because of the location and
symptoms (Yersinia enterocolitica is found
more commonly in the Eastern and Central
part of the U.S. and does not cause buboes)
• D is incorrect as it is associated with GI
symptoms and has different transmission
• E is incorrect as this is a fungal infection that
is commonly transmitted through pigeon
droppings and presents with neurological
findings
118
Section 35 - Enterobacter, Citrobacter, & Serratia marcescens
1. Ptero (Greek for having wings): Enterobacter
2. Mars: Serratia marcescens
3. Orange (citrus fruit) pods: Citrobacter
4. Pink and red atmosphere: gram negative
5. Red tube coming off the winged ship: Enterobacter
is associated with intravascular catheter infections
6. Shields protecting the winged ship from laser
beams: Enterobacter is drug resistant
7. Monkey piloting a fast ship near the winged ship:
Enterobacter is a fast lactose fermenter
8. Attractive pilot in a ship that burns urine for fuel:
Enterobacter causes nosocomial UTIs
9. Two cephalopods: Enterobacter is treated with
second generation cephalosporins
10. Prominent red aura surrounding Mars: Serratia
marcescens produces a red pigment
11. Cat constellation near Mars: Serratia marcescens is
catalase positive
12. Monkey in slow, damaged ship near Mars: Serratia
marcescens is a slow lactose fermenter
13. Attractive pilot in damaged ship losing urine fuel:
Serratia marcescens causes UTIs
14. Two cephalopods: Serratia marcescens is treated
with second generation cephalosporins
15. Monkeys in slow, damaged ship with orange pods:
Citrobacter is a slow lactose fermenter
 119

REVIEW QUESTIONS ?
1. A 6-year-old girl is admitted to the ICU while
undergoing treatment for leukemia. An
intravascular catheter is placed to provide
access for fluid and medication administration.
However, two days later she develops erythema,
tenderness, and drainage surrounding the
access site. The catheter is removed, but the
medical team is concerned about possible
bacteremia. Blood cultures are drawn and
grow gram negative bacilli that rapidly ferment
lactose when placed on MacConkey agar. The
Photo Credit: Riraq25 [CC BY-SA 3.0 (https://creativecommons.org/licenses/ most likely causal organism:
by-sa/3.0)]
Figure 5.2.79 - Gram stain of Enterobacter A. Can be effectively treated with ceftriaxone
B. Produces a red pigment
C. May cause bloody diarrhea
D. Also causes urinary tract infections

• Correct answer: D
• This patient has an Enterobacter infection
• Erythema, tenderness, and drainage
surrounding the access site
• Gram negative bacilli that rapidly
ferment lactose on MacConkey agar
• Enterobacter causes urinary tract
infections
• A is incorrect because ceftriaxone is a third
generation cephalosporin and enterobacter
is resistant to this antibiotic
• B is incorrect because Serratia produces a
Photo Credit: https://en.wikipedia.org/wiki/File:Bloody_bread_-_Serratia_
marcescens_in_action.JPG#file red pigment but is a slow lactose fermenter
Figure 5.2.80 - Red pigment from Serratia on a • C is incorrect because enteric organisms
piece of bread such as Shigella or E. coli may cause bloody
diarrhea but are not associated with
intravascular catheter infections
120
Section 36 - Bartonella henselae
1. Hens: Bartonella henselae
2. Pink sky: gram negative
3. Starry sky: Warthin-Starry stain
4. Farm with animals: zoonotic organism
5. Cat scratching hen: cat scratch fever
6. Granny defending the hen: granuloma formation
7. Hairy armpits: painful axillary lymphadenopathy
8. Man using a $100 bill to patch up injured hen on
a red-stained stretcher: immunocompromised
patients (AIDS patients with CD4 count < 100) may
develop bacillary angiomatosis
9. Scalpel and shirt with circular blood stains: biopsy
will show neutrophilic inflammation
10. Shattered petri dish near car: blood culture-negative
endocarditis
11. Scarecrow leaning up against barn: treat with
macrolides
12. Dirt bike: treat with doxycycline
13. Using a rifle to shoot the cat: treat with rifampin
 121

REVIEW QUESTIONS ?
1. A 27-year-old male presents to the physician
due to pain in the left axilla. Physical
examination reveals an enlarged and tender
lymph node that is palpable under the left axilla.
There is also several scratch marks seen on the
posterior aspect of the left hand. When asked
about the scratches, he states that they were
caused by a new cat he recently purchased.
Which of the following is the best treatment for
this patient’s condition?
A. Azithromycin
Photo Credit: [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)], via B. Ceftriaxone
Wikimedia Commons
C. Daptomycin
Figure 5.2.81 - Warthin-Starry stain D. Metronidazole
E. Amoxicillin

• Correct answer: A
• This patient has an infection caused by
Bartonella henselae (cat scratch disease)
• Recent cat purchase
• Multiple scratches
• Lymphadenopathy in the axilla proximal
to the scratches
• Effective treatment includes using a
macrolide (eg, azithromycin)
• B-E are not used in the treatment of
Bartonella henselae infections
122
Section 37 - Legionella pneumophila
1. Roman legion: Legionella pneumophila
2. Pink sky and water: gram negative
3. Soldier falling out of the boat and swimming to get
back in: facultative intracellular
4. Boats surrounded by lots of water: transmitted
through water sources (eg, air conditioning systems,
hot water tanks)
5. Fire with smoke rising in the air: common in
smokers and in chronic lung disease
6. Helen of Troy wearing expensive blue necklace:
oxidase positive
7. Piles of silver: can be identified using the silver stain
8. Legion shields decorated like the Sistine chapel,
black-sooted faces, and iron javelins: Legionella is
grown on charcoal yeast extract medium buffered
with iron and cysteine
9. Water spilling into the sinking ship: causes watery
diarrhea
10. Man coughing from smoke: causes pneumonia
11. Confused soldier smacked in the head: causes CNS
symptoms (eg, confusion, headaches)
12. Hot fire burning the ship: high fever (>39°C)
13. Ramming spike shaped like the Pontiac symbol:
causes Pontiac fever
14. Salt spilling out of the damaged ship: associated
with hyponatremia
15. Oil and gems spilling out of damaged ship:
diagnosed by detecting antigens in the urine
16. Soldier using zip line: can be treated with
azithromycin
17. Flowers wrapped around the mast: can be treated
with fluoroquinolones
 123

REVIEW QUESTIONS ?
1. A 51-year-old male with a history of chronic
bronchitis is brought to the emergency
department by his wife due to strange behavior
for the past two days. She states that this
morning he got lost driving home from the
grocery store which is only a few blocks away
from their home. She also states that he
complained of diarrhea and a headache the
day before. Physical examination is significant
for a fever of 40.3°C (104°F). The patient is also
Photo Credit: CDC-PHIL [Public domain] mildly disoriented, but the remainder of the
Figure 5.2.82 - Gram stain of Legionella neurological exam is normal. A sputum gram
stain reveals an abundance of neutrophils but
no organisms. What additional finding will most
likely be present in this individual?
A. Gram-positive cocci colonization of the
nares
B. Antigens of the pathogen in the urine
C. Hemolysis due to IgM autoantibodies
D. Antibodies directed against hemagglutinin
and neuraminidase

• Correct answer: B
• The patient has a Legionella infection
• History of chronic bronchitis
• CNS symptoms
Photo Credit: William Cherry [Public domain] • GI symptoms
Figure 5.2.83 - Silver stain of Legionella • High fever
• Abundance of neutrophils but no
organisms seen on gram stain
• Legionella can be diagnosed by
detecting urine antigens
• A is false because it is characteristic of
Staphylococcus aureus
• C is false because it describes the
pathogenesis of Mycoplasma pneumonia
• D is false because it refers to the mechanism
of the Influenza virus

Photo Credit: CDC/Megan Mathias and J. Todd Parker, Courtesy: Public Health
Image Library
Figure 5.2.84 - Buffered charcoal yeast extract agar
124
Section 38 - Campylobacter jejuni
1. Jiu jitsu at the battle of Iwo Jima: Campylobacter
jejuni
2. Pink sky: gram negative
3. Curved mustache: curved bacilli
4. Blue necklace: oxidase positive
5. Man looking at poop on his shoe: fecal-oral
transmission
6. American flag: flagellated (motile)
7. Hot explosion: grows at 42°C
8. Pig symbol on aircraft: pigs are reservoirs
9. Puppy: puppies are reservoirs
10. Stray cat: cats are reservoirs
11. Eating raw meat and drinking raw milk: transmitted
through the ingestion of undercooked meat and
unpasteurized milk
12. Injured men bleeding: causes bloody diarrhea
13. Green berets climbing hill, each one getting more
exhausted toward the top: associated with Guillain-
Barré syndrome (ascending paralysis)
14. Reporter writing things down: associated with Reiter
syndrome (reactive arthritis)
 125

REVIEW QUESTIONS ?
1. A 6-year-old girl is brought to the physician
due to bloody diarrhea that was first noticed
yesterday. She has no significant past medical
history and has not traveled recently. A stool
culture reveals gram-negative curved bacilli
that are oxidase-positive. The causal organism
is most likely transmitted through which of the
following?
A. Contaminated water
Photo Credit: CDC [Public domain]
B. Sheep
C. Sexual contact
Figure 5.2.85 - Gram stain Campylobacter D. Pigs
E. Respiratory droplets

• Correct answer: D
• This patient has a Campylobacter jejuni
infection
• Bloody diarrhea
• Stool culture reveals gram-negative
curved bacilli that are oxidase-positive
• Campylobacter jejuni can be transmitted
through pigs
• A is incorrect because although Vibrio
cholera is a gram-negative curved bacilli
that is oxidase positive and causes diarrhea,
it doesn’t cause bloody diarrhea and is
spread through contaminated water
• B is a reference to Bacillus anthracis which
is not associated with bloody diarrhea
• C is incorrect because sexual contact is not
typically associated with bloody diarrhea
• E is a reference to many organisms such as
Legionella
126
Section 39 - Vibrio cholerae & Vibrio vulnificus
1. Popped collar: Vibrio cholerae
2. Pink sky: gram negative
3. Curved mustache: curved bacillus
4. Flag: flagellated
5. Image of Africa: endemic to developing countries
6. Acidic lemon juice: acid-labile (large inoculum
required)
7. Air mattress pump: proton pump inhibitors increase
the risk of infection
8. Blue necklace: oxidase positive
9. Contaminating water with old food: transmitted via
ingestion of contaminated water
10. Flashlight powered by alkaline batteries: found in
alkaline environments
11. Camping with tents: cholera toxin overactivates
adenylate cyclase resulting in increased levels of
cAMP
12. Knocking over pot of rice: causes “rice-water”
diarrhea
13. Waterfall: causes watery diarrhea
14. Large jug of water: treat with oral rehydration
solution
15. Volvo logo: Vibrio vulnificus
16. Monkey crackers: Vibrio vulnificus ferments lactose
17. Oysters: Vibrio vulnificus is associated with raw
oyster consumption
18. Pack of alcohol: Vibrio vulnificus is associated with
alcohol consumption
19. Sipping near Volvo: Vibrio vulnificus can cause sepsis
20. Dalmatian dog with a liver-shaped spot: Vibrio
vulnificus can cause liver damage
 127

REVIEW QUESTIONS ?
1. A resident physician is working in Ghana on
a humanitarian trip when a 19-year-old male
presents to the clinic with a 3-day history of
watery diarrhea. He states that he recently
drank some water that may have been
contaminated. A stool sample reveals gram-
negative, oxidase-positive, flagellated bacilli.
The resident informs the medical team that his
condition is caused by a toxin that:
A. Invades the gastrointestinal mucosa
B. Results in an absence of neutrophils in the
stool
C. Spreads hematogenously to vital organs
D. Increases levels of cyclic GMP

Photo Credit: CDC [Public domain]

• Correct answer: B
• This patient has a Vibrio cholerae infection
Figure 5.2.86 - Gram stain of Vibrio cholerae
• Recent travel exposure
• Watery diarrhea
• History of drinking contaminated water
• Stool sample with gram-negative,
oxidase-positive flagellated bacilli
• Vibrio cholerae produces a toxin that
results in rice-water diarrhea
• The toxin is non-inflammatory and
results in an absence of neutrophils
in the stool as it does not invade the
gastrointestinal mucosa
• A is characteristic of the inflammatory
diarrheal illnesses caused by Shigella or
Salmonella
• C is incorrect because this is describing
Salmonella which can disseminate
hematogenously
• D is incorrect because Vibrio cholerae
increases the levels of cyclic AMP - not cyclic
GMP
Photo Credit: F1jmm [CC BY-SA 3.0 (https://creativecommons.org/licenses/
by-sa/3.0)]
Figure 5.2.87 - “Rice-water” diarrhea
128
Section 40 - Helicobacter pylori
1. Pile of dirty clothes: Helicobacter pylori
2. Pink walls: gram negative
3. Curved mustache: curved bacillus
4. American flag: flagellated (motile)
5. Silver plate and silverware: can be diagnosed using
silver-based staining methods
6. Antlers: colonizes the antrum
7. Cat on pile: catalase positive
8. Cat urinating on dirty pile: urease positive
9. Blue necklace: oxidase positive
Photo Credit: Ed Uthman, MD [CC BY-SA 2.0 (https://creativecommons.org/
licenses/by-sa/2.0)]
Figure 5.2.88 - Hematoxylin and eosin (H&E) stain
of the gastric mucosa
10. Mattress dipping in the middle with a red spot:
causes peptic ulcer disease
11. Green fart clouds: can cause chronic gastritis
12. Cancer hope ribbon: can cause gastric carcinoma
13. Malt shake: can cause MALT lymphoma
14. Green burp cloud: diagnosed with a urease breath
test
15. Vacuum pump: treated with proton pump inhibitors
16. Ammo belt: treated with amoxicillin
17. Clarinet: treat with clarithromycin
Photo Credit: CDC/Dr. Edwin P. Ewing, Jr. [Public domain]
Figure 5.2.89 - Silver based stain

Figure 5.2.90 - Stomach anatomy and physiology
REVIEW QUESTIONS
1. A 27-year-old male with a history of chronic
arthritis is brought to the emergency
department after an episode of syncope which
occurred an hour ago. He quickly regained
consciousness, but has felt lightheaded since
that time. Additional history reveals that he
began having black tarry stools several days ago.
His temperature is 37°C (98.6°F), pulse is 120/
min, and blood pressure is 80/60. This patient’s
condition is most likely caused by which of the
following?
A. Helicobacter pylori
B. NSAID use
C. Alcohol use
D. Hypertriglyceridemia
129
?
• Correct answer: B
• This patient has a peptic ulcer caused by
chronic NSAID use
• Chronic arthritis → likely taking NSAIDs
• Recent syncope, black tarry stools,
tachycardia, and hypotension → peptic
ulcer and an upper GI bleed
• Chronic NSAID use in a patient with a
painful chronic condition is likely, and
there is no information indicating an
H. pylori infection in the question stem
(answer A)
• C is incorrect because while high
concentrations of alcohol may damage the
gastric mucosal barrier, there is no evidence
that alcohol causes peptic ulcer disease
• D is suggestive of pancreatitis
130
Section 41 - Mycobacterium tuberculosis
1. Tubers: Mycobacterium tuberculosis
2. Microphone: mycolic acid
3. Green acid: acid-fast bacillus
4. Car bomb: carbol fuchsin
5. LeBron James signature: can be grown in
Löwenstein-Jensen medium
6. Smoke: enters the lower lobes of the lungs via
aerosolized droplets
7. Cage: engulfed by alveolar macrophages and
replicates intracellularly
8. Television cord: cord factor creates a “serpentine
cord” appearance under the microscope
9. Tide bleach: produces a virulence factor known as
sulfatide
10. Bleach on the floor in separate puddles: sulfatides
prevent fusion of the phagosome and lysosome
11. Guy purifying clothes: purified protein derivative
(PPD) test
12. Syringe: the BCG vaccine causes false positive PPD
tests
13. Green rays: the IFN-γ release assay (IGRA) has fewer
false positives among people with the BCG vaccine
14. Gong: a Ghon complex may form during primary TB
15. Person sleeping: latent TB
16. Granny: organisms are walled off via granuloma
formation
17. Fibrous ends of the blanket: the infected lung tissue
becomes fibrotic
18. TNT remote: TNF-α inhibitors disrupt granuloma
formation and may “awaken” the infection from its
latent state
19. Emaciated kid: secondary TB occurs as health
declines and the immune system becomes weaker
20. Upstairs: secondary TB affects the upper lobes of
the lungs
21. Skinny: secondary TB presents with weight loss
22. Sweating: secondary TB presents with night sweats
23. Red beet juice near mouth: secondary TB presents
with hemoptysis
24. Heater: secondary TB presents with a fever
25. Millet: miliary TB can occur following secondary TB
or primary progressive TB
26. Pot of water: Pott disease may be seen in miliary TB
27. Hat with cavity due to weight of millet seeds:
cavitary brain lesions may be seen in miliary TB
28. Smear of ripe food: treat primary, secondary, and
miliary TB infections with RIPE therapy
29. Rifle and grandma holding a glass of ice: treat latent
TB with rifampin and isoniazid
 131

Photo Credit: CDC/Dr. George P. Kubica [Public domain], via Wikimedia

Commons
Figure 5.2.91 - Acid-fast stain of Mycobacterium
tuberculosis

Photo Credit: https://en.wikipedia.org/wiki/File:LJ_medium.JPG#file

Figure 5.2.92 - Lowenstein-Jensen medium
132

Figure 5.2.93 - Pathophysiology of Mycobacterium tuberculosis

 133

REVIEW QUESTIONS ?
1. A 57-year-old woman who emigrated to the U.S.
from Thailand several years ago presents to the
emergency department due to night sweats,
fevers, and weight loss. She states that she
first noticed her symptoms approximately one
week ago. Her past medical history is significant
Photo Credit: Yale Rosen from USA [CC BY-SA 2.0 (https://creativecommons.
org/licenses/by-sa2.0)] for rheumatoid arthritis that is well controlled
Figure 5.2.94 - Miliary tuberculosis with infliximab. Physical examination shows
axillary lymphadenopathy. A chest x-ray reveals
a pulmonary infiltrate in the upper lobe of the
left lung. This patient’s condition can be best
explained by which of the following?
A. Idiopathic pulmonary fibrosis
B. Uncontrolled proliferation of Reed-
Sternberg cells
C. Granuloma dysfunction
D. Polymorphonuclear invasion of alveolar
tissue
Photo Credit: CDC/Ronald K. Smithwick [Public domain]
• Correct answer: C
Figure 5.2.95 - “Serpentine cords”
• This patient has reactivation of latent TB
• From Thailand, night sweats, fever,
weight loss, pulmonary infiltrate in the
upper lobe of the left lung → suggestive
of TB
• Infliximab is a TNF-α inhibitor →
granuloma breakdown → reactivation of
latent TB
• Granulomas form around latent TB
Photo Credit: Greg Knobloch [Public domain] through the action of macrophages
Figure 5.2.96 - PPD test which secrete TNF-α which helps form
epithelioid macrophages and giant cells
• Anti-TNF-α medications can cause
sequestered granulomas to break down
which results in the dissemination of
the bacteria
• A is incorrect because while idiopathic
pulmonary fibrosis can cause shortness of
breath, it’s unlikely to cause fever, night
sweats, weight loss
• B is describing cells that are associated with
Hodgkin lymphoma
• D is incorrect because this is describing
pneumonia

Photo Credit: Basem Abbas Al Ubaidi [CC BY 4.0 (https://creativecommons.

org/licenses/by/4.0)]
Figure 5.2.97 - Ghon complex
134
Section 42 - Mycobacterium leprae
1. Leopards: Mycobacterium leprae
2. Acid rain: acid-fast bacillus
3. Car bombs: carbol-fuschin
4. Microphone: mycolic acid
5. Armadillo: armadillos are reservoirs in the U.S.
6. Snow-capped mountains: prefers cool temperatures
7. Prominent red gloves: causes superficial nerve
infections resulting in a glove and stocking loss of
sensation
8. Broken petri dish: cannot be grown in vitro
9. Biopsy dart: diagnosed with a skin biopsy
10. Three-chain fence: diagnosed using polymerase
chain reaction
11. Two lazy leopards: the lepromatous form is
associated with a weak immune response (T helper
type 2 cells are activated)
12. Two leopards high on the hill near high amounts
of green mold: the lepromatous form is associated
with a high bacterial load
13. Lion near the two lazy leopards: the lepromatous
form is associated with leonine facies
14. Skull near the two lazy leopards: the lepromatous
form can be lethal
15. Big tubercle: tuberculoid form
16. Caged leopard: the tuberculoid form is associated
with a strong immune response (T helper type 1
cells are inactivated)
17. The cage and tubercle-ridden man are low on
the hill near small amounts of green mold: the
tuberculoid form is associated with a low bacterial
load
18. Bald patches near tubercle: the tuberculoid form is
associated with hairless skin plaques
19. Deputy: dapsone is used to treat both forms of
leprosy
20. Rifle: rifampin is used to treat both forms of leprosy
21. Lazy leopard eating a clover: clofazimine is added
for patients who have the lepromatous form
 135

Photo Credit: U.S. Department of Health and Human Services [Public domain]
Figure 5.2.98 - Acid-fast stain of Mycobacterium leprae

Figure 5.2.99 - Pathophysiology of Mycobacterium leprae

136

Photo Credit: Rosemary A. Jones [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Figure 5.2.100 - Leonine Facies

REVIEW QUESTIONS
1. A 41-year-old male who recently emigrated
from Nigeria comes to the office due to
a skin lesion on his head. He states that
he first noticed the area a few weeks ago.
Physical examination reveals a hypoesthetic,
hypopigmented lesion on the right side of the
patient’s forehead. Adjacent to the lesion is an
area of baldness extending several centimeters
into his hairline. A biopsy is obtained
and light microscopy reveals numerous
pathogens invading the nerve tissue. Which
of the following is true regarding this patient’s
condition?
A. There is an abundance of Th2 cells in
response to the infection
B. The cell wall of the pathogen contains many
long fatty acids
C. The causal organism prefers warm
temperatures
D. IL-4 is the cytokine involved in this immune
response
137
?
• Correct answer: B
• The patient has the tuberculoid form of
leprosy
• From Nigeria
• Hypoesthetic, hypopigmented lesion
as well as with an area of baldness →
tuberculoid form of leprosy
• Mycobacterium leprae invades the skin
and nerves
• The cell wall of the bacterium has many
long fatty acids which is describing
mycolic acid found in Mycobacterium
leprae
• A is incorrect because this patient has
the tuberculoid form of leprosy which is
characterized by a Th1 response - not a Th2
response
• C is not characteristic of Mycobacterium
leprae (it prefers cool temperatures)
• D is incorrect because IL-4 is more involved
with Th2 responses
138
Section 43 - Mycobacterium avium-intracellulare, Scrofulaceum, and Marinum
1. Aviary: Mycobacterium avium-intracellulare (MAC)
2. Child with a scruffy beard: Mycobacterium
scrofulaceum
3. Marine biologist bitten by piranha: Mycobacterium
marinum
4. Acid pond: acid-fast
5. Microphone: mycolic acid
6. Man in the aviary has a Band-Aid: MAC causes
disease in AIDS patients
7. Bead-like segments in the aviary: MAC causes
lymphadenitis
8. Heat lamp in the aviary: MAC causes a fever
9. Sweating man within the aviary: MAC causes night
sweats
10. Skinny man within the aviary: MAC causes weight
loss
11. Man using a zip line and wearing a shirt with all 50
states: azithromycin is given when the CD4 count is
< 50
12. Spilled medicine container: MAC is often resistant to
multiple drugs
13. Scruffy beard on a child: M. scrofulaceum is
common in children
14. Scruffy child holding a beaded net near his neck:
M. scrofulaceum causes cervical lymphadenitis in
children
15. Marine biologist working closely with piranhas:
M. marinum causes hand infections in aquarium
handlers
 139

REVIEW QUESTIONS ?
1. A 33-year-old male with a history of HIV
presents to the physician due to weight loss,
fever, and a swollen lump in his neck. His
temperature is 38.8°C (101.8°F). Physical
examination reveals a swollen and tender
cervical lymph node. A tissue aspirate of the
swollen lymph node reveals acid-fast bacilli. A
CD4 count is obtained and will most likely reveal
which of the following?
A. 43 cells/microL
Photo Credit: CDC/Dr. Edwin P. Ewing, Jr. [Public domain] B. 97 cells/microL
Figure 5.2.101 - Acid-fast stain of Mycobacterium C. 439 cells/microL
avium-intracellulare D. 991 cells/microL
E. 1,503 cells/microL

• Correct answer: A
• The patient has MAC
• Weight loss
• Fever
• Cervical lymphadenitis
• Tissue aspirate revealed acid-fast bacilli
• HIV diagnosis makes an AIDS-defining
illness such as MAC more likely than the
rare M. scrofulaceaum
• MAC infections are most common when
the CD4 count drops below 50 which
is why these patients may be given
prophylactic azithromycin
• B-E are all >50 cells/microL
140
Section 44 - Borrelia burgdorferi
1. Burglar: Borrelia burgdorferi
2. Spiral staircase: spirochete
3. “Northeast corner” sign in the northeast part of the
image: common in the northeastern part of the U.S.
4. Tic tacs near exit sign: transmitted through the
Ixodes tick
5. Anne of Green Gables: the Ixodes deer tick is also a
vector for Anaplasma and Babesia
6. Games: can be visualized using the Giemsa stain
7. Deer chasing a mouse: deer and mice are reservoirs
and important to the tick life cycle
8. Target: stage 1 is associated with a “bulls-eye” rash
known as erythema migrans
9. Sweat: stage 1 is associated with flu-like symptoms
Photo Credit: Content Provider(s): CDC [Public domain]
Figure 5.2.102 - Spirochetes via dark-field
microscopy
10. Bell: stage 2 is associated with Bell’s palsy
11. Car on fire: stage 2 is associated with carditis
12. Blocking customers from car store: stage 2 is
associated with atrioventricular block
13. Red knees and elbows: stage 3 is associated with
migratory arthritis
14. Water all over guy’s head: stage 3 is associated with
encephalitis
15. Dirt bike: treat with doxycycline
16. Ammo near pregnant woman and child: treat with
amoxicillin (pregnant women and children)
17. Cephalopod toy: treat with 2nd generation
cephalosporins (pregnant women and children)
Photo Credit: Courtesy of the U.S. Department of Health and Human Services
Figure 5.2.103 -  Ixodes deer tick
 141

Photo Credit: Alan R. Walker [CC BY-SA 3.0 (https://creativecommons.org/ Photo Credit: https://upload.wikimedia.org/wikipedia/commons/1/1d/
licenses/by-sa/3.0)] Bellspalsy.JPG

Figure 5.2.104 - Giemsa stain of Borrelia Figure 5.2.106 - Bell’s palsy

REVIEW QUESTIONS ?
1. A 50-year-old female presents to the physician
due to a rash on her leg that she first noticed
yesterday. She also states that she has felt
general malaise since returning home from a
hiking trip to the Appalachian mountains three
days ago. Physical examination reveals a rash
on the left leg with a central area of erythema
and a surrounding erythematous ring. If left
untreated, which of the following complications
is most likely to occur in this patient?
A. Pneumonia
B. Meningitis
C. Arthritis
D. Hepatitis
E. Aplastic anemia
Photo Credit: James Gathany, Content Provider(s): CDC/James Gathany
[Public domain] • Correct answer: C
Figure 5.2.105 - Erythema migrans • This patient has erythema migrans
associated with stage 1 of Lyme disease
• Recently travel to the Appalachian
mountains (east coast of the U.S.)
• Rash on the left leg with a central
area of erythema and a surrounding
erythematous ring → erythema migrans
(bulls-eye rash) → stage 1
• Migratory arthritis is a common
complication if left untreated
• A, B, D, and E are not commonly associated
with Lyme disease
142
Section 45 - Leptospira interrogans
1. Spear: Leptospira interrogans
2. Spiral waves: spirochete
3. Fishing hook near contaminated water:
hook-shaped ends commonly found in water
contaminated with animal urine
4. Tropical trees: leptospirosis is prevalent in the
tropics
5. Surfer: leptospirosis is prevalent among surfers
6. Yellow surfboard: leptospirosis can cause jaundice
7. Sunglasses and looking away from the sun:
leptospirosis can cause photophobia
8. Blood spattered on sunglasses: leptospirosis can
cause conjunctival erythema
9. Sweating surfer: leptospirosis causes flu-like
symptoms including myalgias
10. Whale: Weil disease
11. Dalmatian with liver-shaped spot: Weil disease can
cause liver dysfunction
12. Yellow surfboard: Weil disease can cause jaundice
13. Heat lamp: Weil disease can cause a fever
14. Uncontrolled bleeding: Weil disease can cause
hemorrhage and anemia
15. Kidney-shaped shrimp: Weil disease can cause renal
failure
 143

REVIEW QUESTIONS ?
1. A 24-year-old male presents to the physician
due to myalgias and a headache. He states that
he first noticed his symptoms after returning
home from a surfing trip to Hawaii two days
ago. Physical examination reveals conjunctival
erythema. The physician suspects a spirochete
infection and immediately begins antibiotic
therapy. Which of the following complications
is most likely associated with this patient’s
condition?
Photo Credit: CDC Public Health Image Library. CDC/NCID/HIP/Janice Carr A. A painful genital ulcer
(PHIL #1220) B. A maculopapular rash on the trunk
Figure 5.2.107 - Electron microscopic image of C. A painless genital ulcer
Leptospira interrogans D. Renal failure

• Correct answer: D
• This patient has an infection caused by
Leptospira interrogans
• Surfing in Hawaii
• Developed myalgias, a headache, and
conjunctival erythema
• A spirochete infection is suspected
→ Leptospira interrogans is the likely
cause
• Weil disease can cause renal failure in
individuals infected with Leptospira
interrogans
• A is associated with Haemophilus ducreyi
• B is incorrect as it is associated syphilis
which has a rash that affects the palms and
soles
• C is describing the classic lesion seen in
syphilis (painless chancre)
144
Section 46 - Treponema pallidum
1. Paladin: Treponema pallidum
2. Spiral staircase: spirochete
3. Fighting dark creature with magic: dark field
microscopy can identify Treponema pallidum
4. Armor with the letter “S”: sexually transmitted
infection
5. Hammer: Jarisch-Herxheimer reaction
6. Skull symbol on the hammer: Jarisch-Herxheimer
reaction occurs following the destruction of the
organism
7. Hammer embedded with copper pennies:
symptoms associated with the Jarisch-Herxheimer
reaction begin following treatment with penicillin
8. Shielding cane attack: primary syphilis presents with
a painless genital chancre
9. Spilling vitriol: VDRL test
10. Tombstone reading “RIP”: RPR test
11. Heart and bones that resemble phospholipids are
poking up from the ground near the vitriol and
“RIP” tombstone: the presence of anticardiolipin
antibodies indicates a positive test result
12. Fire arrow shot between the goblin’s eyes: the FTA-
ABS test is the “confirmatory” test
13. Palms and soles with hair and bumps: secondary
syphilis may present with a maculopapular rash
involving the trunk, palms, and soles
14. Lumpy flail: secondary syphilis may present with a
wart-like lesion on the genitals known as condyloma
lata
15. Beaded net: secondary syphilis may present with
lymphadenopathy
16. Bald patches on mangy monster: secondary syphilis
may present with patchy hair loss
17. Grandpa-looking wizard: tertiary syphilis may
present with gummas
18. Gannondolf wearing a hat: neurosyphilis is a
common complication of tertiary syphilis
19. Damaged columns: tertiary syphilis causes tabes
dorsalis (demyelination of the nerves within the
dorsal column)
20. Aorta-shaped tree: tertiary syphilis may cause
aortitis resulting in a tree barking appearance of the
aorta
21. Eyes appearing angry and focused: tertiary syphilis
may present with Argyll Robertson pupils
22. Hobbit with swollen red knees: tertiary syphilis may
present with neuropathic arthropathy (Charcot
joint)
23. Baby Balrog: congenital syphilis
24. Balrog’s notched teeth: congenital syphilis may
cause notched teeth
25. Intricate horns near the ears: congenital syphilis
may cause hearing loss

26. Odd-shaped nose: congenital syphilis may cause
saddle nose
27. Fire coming out of mouth, nose, and head:
congenital syphilis may cause snuffles (nasal
discharge laden with Treponema pallidum)
28. Wide openings near the sides of the mouth:
congenital syphilis may cause rhagades (wrinkled
skin and linear scars at the angle of the mouth)
Photo Credit: Content Providers: CDC/C.W. Hubbard [Public domain]
Figure 5.2.108 - Dark-field photomicrograph of
Treponema pallidum
Photo Credit: Courtesy of the U.S. Department of Health and Human Services
and M.Rein
Figure 5.2.109 - Chancre
145
29. Deformed shins: congenital syphilis may cause saber
shins
30. Fighting the Balrogs using a penny-based spell:
congenital syphilis can be prevented if the mother is
treated with penicillin early during pregnancy
31. Pennies on the hammer and used against the
Balrog: syphilis is treated with penicillin
Photo Credit: Herbert L. Fred, MD, Hendrik A. van Dijk [CC BY-SA 3.0 (https://
creativecommons.org/licenses/by-sa/3.0)]
Figure 5.2.110 - Maculopapular rash
Photo Credit: CDC/Robert Sumpter [Public domain]
Figure 5.2.111 - Maculopapular rash on the palms
146

Photo Credit: Courtesy of the U.S. Department of Health and Human Services
and Susan Lindsley
Figure 5.2.112 - Condyloma lata Photo Credit: Courtesy of the U.S. Department of Health and Humna Services
and Susan Lindsley
Figure 5.2.115 - Notched teeth

Photo Credit: CDC [Public domain]

Figure 5.2.113 - Gumma

Figure 5.2.114 - Cross section of the spinal cord

 147

REVIEW QUESTIONS ?
1. A 23-year-old male comes to the physician due
to a small painless lesion on his penis that he
noticed yesterday. He is concerned he may have
a sexually transmitted infection because 4 days
ago he had unprotected sexual intercourse with
a prostitute. Physical examination reveals a
painless ulcer on the shaft of the penis. A serum
Venereal Disease Research Laboratory (VDRL)
test is negative. Which of the following should
be performed to make an accurate diagnosis of
this patient’s condition?
A. The rapid plasma reagin (RPR) test
B. Repeat the Venereal Disease Research
Laboratory (VDRL) test
C. The Toluidine Red Unheated Serum Test
(TRUST)
D. The fluorescent treponemal antibody
absorption (FTA-ABS) test

• Correct answer: D
• This patient has a painless lesion on his
Photo Credit: https://en.m.wikipedia.org/wiki/File:Saddle_nose_38.jpg penis (chancre), which is a feature of
Figure 5.2.116 - Saddle nose primary syphilis
• The VDRL is negative but this does not
rule out Treponema pallidum infection
due to the time it takes to develop an
immune response (about 4 weeks)
• False negatives are common early in the
course of infection
• The fluorescent treponemal antibody
absorption (FTA-ABS) test is a
confirmatory test that detects the
presence of Treponema pallidum
antigens and should be performed in
this case
• Always remember to perform both
Photo Credit: Courtesy of the U.S. Department of Health and Humnan a nontreponemal test (VDRL or RPR)
Services and Robert Sumpter and a treponemal test (FTA-ABS) when
Figure 5.2.117 - Rhagades diagnosing cases of syphilis
• Answers A-C are incorrect because they
are all nontreponemal tests which are
based upon the detection of anticardiolipin
antibodies (the patient already had the
nontreponemal VDRL test so it would be
pointless to perform another test with a
similar mechanism)
148
Section 47 - Chlamydia trachomatis, Chlamydophila pneumoniae, and Chlamydophila
psittaci
1. Clams: Chlamydia
2. Letter “S” on shirt: most serotypes of  Chlamydia
trachomatis are sexually transmitted
3. Cage: obligate intracellular (cannot make own ATP)
4. Hugging elementary school kids: elementary bodies
enter the cell via endocytosis
5. Rakes inside school: Reticulate bodies replicate
inside of the cell by fission
6. Kids leaving elementary school: Reticulate bodies
are reorganized into elementary bodies, released
from the cell, and then infect adjacent cells
7. Broken mirror: the cell wall lacks muramic acid
8. Games: identified using the Giemsa stain
9. Gnats: diagnosed with NAAT (amplifies bacterial
DNA or RNA sequences using PCR)
10. Apples: serotypes A, B, and C
11. Dog: serotypes D-K
12. Lamp: serotypes L1, L2, and L3
13. Holding hands: serotypes A, B, and C exhibit hand-
to-hand transmission
14. Blind African American man: serotypes A, B, and C
are common in Africa and can cause trachoma
15. Pelvis on fire: serotypes D-K cause urethritis and PID
16. Pregnant woman partially inside and outside of car:
serotypes D-K cause PID which increases the risk of
ectopic pregnancy
17. Red car fragments and coughing babies: serotypes
D-K cause neonatal pneumonia with eosinophilia
18. Two babies with red eyes: serotypes D-K cause
neonatal conjunctivitis 1-2 weeks after birth
19. Limping granny: serotypes L1, L2, and L3 cause
lymphogranuloma venereum
20. Cup: serotypes L1, L2, and L3 cause painless genital
ulcers
21. Swollen lesions on side of legs: serotypes L1, L2, and
L3 cause painful inguinal buboes
22. Dirt bike: serotypes L1, L2, and L3 are treated with
doxycycline
23. Writing: Reiter syndrome
24. Gondola toys: Gonorrhoeae coinfection
25. New mower with clam logo: Chlamydophila
pneumoniae
26. Pistachios: Chlamydophila psittaci
27. Smoke: C. pneumoniae and C. psittaci are
transmitted through aerosolized droplets
28. Coughing guys: C. pneumoniae and C. psittaci cause
pneumonia
29. Blue bird: birds are reservoirs for C. psittaci
30. Trident: treat with ceftriaxone
31. Zip-line: treat with azithromycin

REVIEW QUESTIONS
1. A 12-day-old infant is brought to the emergency
Photo Credit: Huckfinne [Public domain]
Figure 5.2.118 - Life cycle of Chlamydia trachomatis
Photo Credit: Doctors E. Arum and N. Jacobs [Public domain]
Figure 5.2.119 - Giemsa stain of Chlamydia
149
?
department by his mother due to red eyes.
She states that she did not have prenatal care
due to financial concerns, but that the boy
was delivered at home without complications.
Physical examination reveals erythema and
mucopurulent discharge surrounding both eyes.
The infectious serotype responsible for this
patient’s condition may also cause:
A. Groin pain and a painless genital ulcer
B. Trachoma
C. Septic arthritis
D. Pelvic inflammatory disease
• Correct answer: D
• This patient has neonatal conjunctivitis
caused by Chlamydia trachomatis
• Normal onset is 5-14 days after birth
• Specifically caused by serotypes D-K
• Serotypes D-K also cause pelvic
inflammatory disease
• A is incorrect because it describes
lymphogranuloma venereum which is
caused by serotypes L1, L2, and L3
• B is incorrect because this is the leading
cause of blindness in the world and is
caused by serotypes A, B, and C
• C is incorrect because it is a complication
associated with Gonorrhea but Gonorrhea
causing neonatal conjunctivitis typically
occurs 2-5 days after birth
150
Section 48 - Coxiella burnetii
1. Brunette queen: Coxiella burnetii
2. Pink sunset: gram negative
3. Queens crown: causes Q fever
4. Cow placenta: transmitted through the aerosols of
cattle amniotic fluid
5. Sheep wool: transmitted through the aerosols of
sheep amniotic fluid
6. Plate of snails: a sporulation-like process protects
the organism from harsh environmental conditions
7. Caged sheep: obligate intracellular organism
8. Black horses: a rash is rarely seen in patients with Q
fever
9. Coughing stepsister: patients with Q fever may
present with pneumonia
10. Liver-shaped spot: patients with Q fever may
present with hepatitis and transaminitis
11. Sweating stepsister: patients with Q fever may
present with flu-like symptoms
12. Broken plate: patients with Q fever may present
with thrombocytopenia
13. Broken petri dish near cart: patients with Q fever
may present with culture-negative endocarditis
14. Dirt bike: treat with doxycycline
 151

REVIEW QUESTIONS
1. A 27-year-old male presents to the emergency
Photo Credit: CDC Public Health Image Library [Public domain]
Figure 5.2.120 -  Gram stain of Coxiella burnetii
?
department due to a subjective fever, myalgias,
and shortness of breath for the past several
days. He has also noticed strange bumps on the
pads of his fingers that are quite tender. When
asked about recent changes in his life he states
that approximately one month ago he was hired
to work on a dairy farm. Physical examination
reveals a cardiac murmur and tender raised
lesions on his finger pads. Blood cultures are
obtained but no organisms are grown. Which
of the following additional findings would most
likely be observed in this patient?
A. An AST of 19 U/L (normal: 8-20 U/L)
B. A platelet count of 73,000/mm3 (normal:
150,000-400,000/mm3)
C. A hemoglobin of 10.4 g/dL (normal: 13.5-
17.5 g/dL)
D. A chest radiograph with bilateral hilar
adenopathy

• Correct answer: B
• This patient has Q fever
• Subjective fever
• Myalgias
Photo Credit: Roberto J. Galindo [CC BY-SA 4.0 (https://creativecommons.org/ • Shortness of breath
licenses/by-sa/4.0)] • History of working on a dairy farm
Figure 5.2.121 -  Osler’s nodes • Osler nodes and negative blood
cultures → culture-negative bacterial
endocarditis
• Patients with Q fever may have
thrombocytopenia
• A is incorrect because Q fever also causes
hepatitis so a normal AST would be less
likely than an elevated AST
• C is incorrect because anemia is an
extremely rare finding in patients with Q
fever
• D is incorrect because while fever can cause
pneumonia, this description is suggestive of
sarcoidosis - not pneumonia
152

Section 49 - Gardnerella vaginalis

1. Garden: Gardnerella vaginalis 7. Roses: inflammation caused by overgrowth of

2. Clue: clue cells
3. Decayed skin edges: stippled edges
4. Gray skin: grayish vaginal discharge
5. Fish: fishy smell
6. Vagina shaped flower on shield: painless vaginitis
normal vaginal flora
8. Blue and red garden bugs: gram variable
9. Cleaning lady: clindamycin as treatment
10. Bleach: vaginal pH>4.5 (alkaline)
11. Metro: metronidazole as treatment

REVIEW QUESTIONS
1. A 29-year-old female presents to the physician
Photo Credit: CDC/M. Rein [Public domain], via Wikimedia Commons
Figure 5.2.122 - Clue cells
153
?
complaining of vaginal discharge with a fishy
odor for the past 4 days. The physician obtains
a sample of the discharge for laboratory tests.
Following microscopic examination, the lab does
not identify any fungi, protozoa, or bacteria
foreign to the vagina. Epithelial cells covered
with normal vaginal flora were seen. What
is the likely pH range of the patient’s vaginal
discharge?
• Correct answer: pH > 4.5
• Gardnerella vaginalis infection is suspected
due to the following:
• Vaginal discharge with a fishy odor
• Clue cells (epithelial cells covered with
normal vaginal flora)
• Lack of fungi makes Candidal vaginitis
unlikely
• Lack of protozoa makes Trichomonas
vaginalis unlikely
154

Section 50 - Mycoplasma pneumoniae

1. Plasma alien: Mycoplasma pneumoniae 8. Snow and cold: agglutination and hemolysis occurs
2. Blobby mass: Mycoplasma lacks a cell wall at cold temperatures
3. Coughing: causes pneumonia 9. X-ray machine damaging alien blob: chest
4. Eaten man: grows on Eaton agar radiographs reveal nodular densities
5. College dorm: outbreaks common with young adults 10. Wincing monster: infection causes headaches
(<30) in dormitories 11. Pennies going right through the alien: the absence
6. Military: outbreaks common with military recruits of a cell wall confers beta-lactam resistance
(and prisons) 12. Stick with flowers: treat with fluoroquinolones
7. Snowflakes and bleeding alien: IgM antibodies cause 13. Dirtbike: treat with doxycycline
cold agglutination and hemolysis 14. Scarecrow: treat with macrolides

 
Photo Credit: Martin Brandli (brandlee86) [CC BY-SA 2.5 (https://creativecommons.org/licenses/by-sa/2.5)]
Figure 5.2.123 - IgM antibodies
 155

REVIEW QUESTIONS ?
1.  A 23-year-old female presents to her
primary care physician with persistent
fatigue, headaches and a cough. She states
she is a freshman at the local college and
recently moved into a nearby dormitory.
Further history demonstrates that several
of her classmates have also had similar
symptoms. Her sputum is collected for
staining and culturing. The gram stain does
not reveal the presence of any organisms,
and the organism only grows when cultured
on Eaton agar. Based on the information
above, which of the following is most likely
true regarding her infection?
A. A broad-spectrum antibiotic such as
vancomycin should be used
B. Her blood would agglutinate if collected in a
test tube and warmed
C. A chest radiograph would show
enhancement of an entire lobe
D. Azithromycin will likely kill the suspected
infectious organism

• Correct answer: D
• Azithromycin is a type of macrolide,
a class of drugs that effectively kill
Mycoplasma pneumoniae
• A is incorrect because vancomycin works
by targeting the cell wall, something that
Mycoplasma pneumoniae lacks
• B is incorrect because her blood would
agglutinate at cold temperatures, not hot
temperatures
• C is incorrect because a chest radiograph
would show scattered nodules, not lobar
pneumonia
156
Section 51 - Rickettsia prowazekii, Rickettsia rickettsii, and Rickettsia typhi
1. Rocky Mountains: Rocky mountain spotted fever
2. Destroyed cabin walls: no cell wall
3. Spots: Rocky mountain spotted fever
4. Man dressed as a tick: spread by tick bites
5. Tied at wrists and ankles: rash starts at wrists and
ankles
6. Delirious: confusion
7. Sweating: can cause fevers and sweats
8. Weary muscles: cause muscle aches
9. Vomiting: can cause projectile vomiting
10. Tennis racket: Rickettsia rickettsii causes Rocky
mountain spotted fever
11. Typhoon warning sign: Rickettsia typhi
12. Flea-phoon: Rickettsia typhus is spread by flea bites
13. Fleas on belly: Typhus rash starts on the trunk
before spreading to the rest of the body (spares
palms and soles)
Photo Credit: CDC [Public domain]
Figure 5.2.124 - Rocky Mountain Spotted Fever
14. Prowling bug: Rickettsia prowazekii
15. Prowling bug and fleas on belly: Rickettsia
prowazekii can also cause typhus
16. “Pedicure party”: Pediculus species transmit
Rickettsia prowazekii
17. Eggs carried by boat to a distant land: Rickettsia
prowazekii causes epidemic typhus
18. Typhoon sign: Rickettsia typhi causes endemic
typhus
19. Caged monster: Rickettsia species are obligate
intracellular bacteria
20. Chlorine: can treat with chloramphenicol
21. Dirtbike: first-line treatment is doxycycline
22. Pregnant woman on dirt bike: caution when
prescribing doxycycline to pregnant individuals
23. Whale: diagnosed with Weil-Felix test
24. Games: diagnosed with Giemsa stain

Figure 5.2.125 - Weil Felix Test
REVIEW QUESTIONS
1. A 19-year-old female presents to the physician
with a pruritic rash on her abdomen, arms
and legs. She states that the rash started on
her abdomen soon after she brought a new
dog home from the local pound. The physician
recognizes that the rash is likely caused by a
rickettsial infection. The physician tells the
patient that he sees this type of infection three
or four times each year and has for the past 20
years. The physician also indicates that he has
never seen this infection prior to moving to the
area. Which of the following is true regarding
the most likely causal organism?
A. It will appear purple on a gram stain
B. It is spread by ticks endemic to the area
C. It is spread by an organism belonging to the
pediculus genus
D. A tetracycline should be administered
157
?
• Correct answer: D
• The patient likely has typhus from R.
typhi for the following reasons:
• Her rash started on her trunk and
spread to her arms and legs
• The infection is endemic to the
region
• Doxycycline is a tetracycline that
effectively treats Rickettsial infections.
• A is incorrect because Rickettsial species
do not gram stain well, which is why the
Giemsa stain or the Weil-Felix test are
required
• B is incorrect because fleas transmit
endemic typhus, not ticks
• C is incorrect because lice (pediculus
species) transmit epidemic typhus (R.
prowazekii), not endemic typhus (R. typhi)
158
Section 52 - Ehrlichia & Anaplasma
1. Early alarm clock: Ehrlichia
2. Anne of Green Gables: Anaplasma
3. Destroyed wall: no cell wall
4. Hamster cage: obligate intracellular
5. 2E on the east side of picture: common in the East
Coast of the U.S.
6. Tic Tacs: transmitted by the Ixodes deer tick
7. Sick with thermometers in mouths: Ehrlichia and
Anaplasma cause nonspecific flu-like symptoms
8. Completely black blankets: a rash is uncommon
9. Balloon that resembles monocytes: Ehrlichia may be
seen in the cytoplasm of monocytes on a peripheral
blood smear
10. Grain crumbs: Anaplasma may be seen in the
cytoplasm of granulocytes on a peripheral blood
smear
11. Dirt bikes: treat with doxycycline

REVIEW QUESTIONS
1. A 12-year-old boy is brought to the physician
Photo Credit: CDC [Public domain]
Figure 5.2.126 - Ehrlichia within a monocyte
Photo Credit: Alan R. Walker [CC BY-SA 3.0 (https://creativecommons.org/
licenses/by-sa/3.0)]
Figure 5.2.127 - Anaplasma within a granulocyte
159
?
24 hours after developing chills, myalgias,
and a subjective fever. He recently returned
home from a scouting trip to Connecticut.
His temperature is 38.9°C (102°F), pulse is
114/min, and blood pressure is 112/79. A
peripheral blood smear is obtained and reveals
an organism present within the cytoplasm of
granulocytes. The most likely causal organism
shares a vector with which of the following?
A. Treponema pallidum
B. Coxiella burnetii
C. Leptospira interrogans
D. Borrelia burgdorferi
• Correct answer: D
• Reasons why this patient has an Anaplasma
infection:
• The patient has chills, myalgias, and a
fever since returning home from a trip
to Connecticut
• A peripheral blood smear has revealed
an organism present in the cytoplasm of
granulocytes
• Anaplasma and Borrelia burgdorferi are
both transmitted through the Ixodes deer
tick
• A is incorrect because this is a sexually
transmitted infection
• B is incorrect because this is transmitted
through aerosols of cattle and sheep
amniotic fluid
• C is incorrect because this is transmitted
through water contaminated with animal
urine
160
Section 53 - Miscellaneous Organisms
1. B​ lue sky: gram positive
2. Whipping out eyeball: Tropheryma whipplei
3. Stealing many small purple balls: periodic acid-Schiff
(PAS) positive
4. Man lacking several toes: Lactobacillus
5. Man spraying potent antibiotics and killing green in
the area: antibiotics can reduce the population of
Lactobacilli in the vagina
6. Planting Canadian flag in the now open area: a
decreased population of Lactobacilli increases the
risk of vaginal Candidiasis
7. Garden growing in the now open area: a decreased
population of Lactobacilli increases the risk of
bacterial vaginosis (Gardnerella vaginalis)
8. Pepto-bismol: Peptostreptococcus spp.
9. Wearing protective mouth mask:
Peptostreptococcus is anaerobic
10. Pouring Pepto-bismol into Molotov cocktail:
Peptostreptococcus is associated with alcoholic
aspiration
11. Toxic fluid creating cube-shaped ulcers in the grass:
Peptostreptococcus is associated with decubitus
ulcers
12. Using surgical tubing as funnel: Peptostreptococcus
is associated with surgical drain infections
13. Red colors: gram negative
14. Lighting a fuse: Fusobacterium spp.
15. Wearing protective mouth mask: Fusobacterium is
anaerobic​
16. Using surgical tubing as funnel: Fusobacterium is
associated with surgical drain infections​
17. Molotov cocktails near fuse: Fusobacterium is
associated with alcoholic aspiration
18. Molotov cocktails burning cube-shaped ulcers in the
grass: Fusobacterium is associated with decubitus
ulcers
19. Wheel of provolone cheese: Prevotella spp.
20. Wearing protective mouth mask: Prevotella is
anaerobic
21. Molotov cocktails burning cube-shaped ulcers in the
grass: Prevotella is associated with decubitus ulcers​
22. Molotov cocktails near fuse: Prevotella is associated
with alcoholic aspiration
23. Using surgical tubing as funnel: Prevotella is
associated with surgical drain infections​​
24. Box labeled “FRAGILE”: Bacteroides fragilis
25. Cube-shaped grass ulcers near the “FRAGILE” box:
Bacteroides fragilis is associated with decubitus
ulcers
26. Molotov cocktails within “FRAGILE” box: Bacteroides
fragilis is associated with alcoholic aspiration
27. Surgical tubing as funnels: Bacteroides fragilis is
associated with alcoholic aspiration

28. “FRAGILE” box sitting on sewer drain: Bacteroides
fragilis is not part of the normal colonic flora
29. Blast from “FRAGILE” box that exposes abdominal
organs: Bacteroides fragilis is associated with intra-
abdominal infections
30. Bird holes: Burkholderia cepacia complex
31. Water softener with dysregulated, lost salt:
Burkholderia infections occur in patients with cystic
fibrosis
32. Water softener dust causing a cough: Burkholderia
causes pneumonia in cystic fibrosis patients
33. Cat ready to attack bird: Burkholderia is catalase
positive
34. Timeshares in the Bahamas: Acinetobacter
baumannii
35. Cat biting Bahamas salesman: Acinetobacter
baumannii is catalase positive
36. Coughing from smoke due to overheating car:
Acinetobacter baumannii causes pneumonia
37. Computer hacker: HACEK (Haemophilus
haemolyticus + parahaemolyticus, Aggregatibacter,
Cardiobacterium, Eikenella, and Kingella)
38. Car running over the petri dish: HACEK organisms
are often the cause of culture negative endocarditis
39. Club-wielding granny: Klebsiella granulomatis
161
40. Club-wielding granny​wearing African apparel:
Klebsiella granulomatis is most prevalent in Africa
41. Beef and blood on crotch: Klebsiella granulomatis
causes beefy, red genital ulcers (granuloma
inguinale)
42. Stains do not cause pain: ulcers are painless
43. Club-wielding granny​wearing a scarlet “S”:
Klebsiella granulomatis is sexually transmitted
44. Half-bloody (bipolar) cow: Klebsiella granulomatis
demonstrates bipolar Donovan bodies on
microscopy
45. Rubber duckies: Haemophilus ducreyi
46. Painful groin hit from ducky impact: Haemophilus
ducreyi​causes painful genital ulcers
47. Green decorative beads lining the groin:
Haemophilus ducreyi​causes inguinal
lymphadenopathy
48. Mom wearing scarlet “S”: Haemophilus ducreyi​is
sexually transmitted
49. Urinating on plasma television: Ureaplasma spp.
50. Urine pooling on the ground: Ureaplasma is urease
positive
51. Electric shock to the urethra: Ureaplasma causes
urethritis
52. Electric shock destroying brick wall: Ureaplasma has
no cell wall and does not gram stain well
162

Organism Morphology Other Features Clinical Significance

• Diagnose with
Gram positive
Tropheryma whipplei periodic acid-Schiff • Whipple disease
bacilli
(PAS) stain
• Population decreased by antibiotics and
Gram positive • Part of normal
Lactobacillus douching → predisposes to Candida and
bacilli vaginal flora
Gardnerella vaginalis infections
• Decubitus ulcers
Peptostreptococcus Gram positive
• Anaerobic • Can infect surgical drains
spp. cocci
• Associated with alcoholic aspiration
• Decubitus ulcers
Gram negative
Fusobacterium spp. • Anaerobic • Can infect surgical drains
bacilli
• Associated with alcoholic aspiration
• Decubitus ulcers
Gram negative
Prevotella spp. • Anaerobic • Can infect surgical drains
bacilli
• Associated with alcoholic aspiration
• Decubitus ulcers
Gram negative • Anaerobic • Can infect surgical drains
Bacteroides fragilis
bacilli • Normal colonic flora • Associated with alcoholic aspiration
• Intra-abdominal infections
Burkholderia cepacia Group of gram
• Catalase positive • Pneumonia in cystic fibrosis patients
complex negative bacilli
• Community acquired pneumonia
Acinetobacter Gram negative
• Catalase positive • Associated with mechanical ventilation/
baumannii coccobacilli
intubation
Gram negative • Sexually transmitted • Chancroid (painful genital ulcers)
Haemophilus ducreyi
coccobacilli infection • Inguinal lymphadenopathy
• Sexually transmitted
infection
Klebsiella • Granuloma inguinale (painless beefy red
Gram negative • Bipolar staining
(calymmatobacterium) ulcer that easily bleeds)
bacilli seen on microscopy
granulomatis • Rare in USA
(Donovan bodies in
cytoplasm)
HACEK (Haemophilus
haemolyticus +
parahaemolyticus, Gram negative • Associated with culture negative
Aggregatibacter, bacilli endocarditis
Cardiobacterium,
Eikenella, and Kingella)
Pleomorphic (no
Ureaplasma
cell wall: poor • Urease positive • Urethritis
urealyticum
gram staining)
Table 5.2.1 - Miscellaneous organisms
 163

Photo Credit: By Ed Uthman via Flickr (CC SA 2.0)

Figure 5.2.128 - Intestinal biopsy in Whipple disease

Photo Credit: Public domain via Flickr

Figure 5.2.131 - Bipolar Donovan bodies from
granuloma inguinale ulcer biopsy

Photo Credit: GerardM via Wikimedia Commons

Figure 5.2.129 - Granuloma inguinale caused by
Klebsiella granulomatis (male)

Photo Credit: GerardM via Wikimedia Commons

Figure 5.2.130 - Granuloma inguinale caused by
Klebsiella granulomatis (female)
164

REVIEW QUESTIONS ?
1. A 45-year-old male with a history of alcoholism
presents to the emergency department with a
painful, productive cough. He reports that his
symptoms began shortly after a visit to a local
bar. Upon awakening, he discovered that he was
face down in a puddle of beer. A radiograph of
his chest is obtained which is suggestive of lobar
pneumonia. His sputum is cultured and a gram
stain reveals a gram negative bacillus. Which
of the following is the most likely infectious
organism?
A. Burkholderia cepacia complex
B. Tropheryma whipplei
C. Haemophilus ducreyi
D. Peptostreptococcus spp.
E. Fusobacterium spp.

• Correct answer: E
• The following items are consistent with
a Fusobacterium infection:
• Pneumonia
• Alcoholic aspiration
• Gram negative organism
• Choice A is incorrect because Burkholderia
cepacia complex occurs almost exclusively
with cystic fibrosis, a disease not suspected
in this patient
• Choice B is incorrect because Tropheryma
whipplei is a gram positive organism that
causes Whipple disease
• Choice C is incorrect because Haemophilus
ducreyi causes painful genital ulcers, not
pneumonia
• Choice D is incorrect because
Peptostreptococcus is gram positive
 165

FUNGI

Figure 5.3.1 - Fungi overview figure

166

Section 1 - Histoplasma capsulatum

1. Watching the History channel: Histoplasma 13. Shawl with an “A” on it: treat local infections with
capsulatum azole medications (eg, itraconazole, fluconazole,
2. Butterfly: dimorphic (mold at 20°C and yeast at voriconazole)
37°C) 14. Amphibian running from dog: treat systemic
3. Ohio state shirt and Mississippi mud pie: common in infections with amphotericin B
the Mississippi and Ohio River valleys
4. Pet bird and pet bat: found in droppings from the
starling bird or bats
5. Caves shown on television: commonly found in
caves
6. Injured man on stretcher: can disseminate in
immunocompromised individuals
7. Coughing grandson: can cause pneumonia
8. Specks of chocolate on tongue: can cause palatal
and tongue ulcers
9. Dalmatian dog with liver-shaped spot: can cause
hepatosplenomegaly
10. Granny: can form granulomas Photo Credit: Histoplasmosis by Yal Rosen via Flickr.com

11. Bird cage with bird food: microscopy may reveal Figure 5.3.2 - Histoplasma capsulatum yeast in
macrophages filled with Histoplasma yeast macrophages
12. Gems on the counter near the urinating man:
diagnosed by detecting antigens in the urine or
serum
 167

Photo Credit: Mold (left): Bob Blaylock [CC BY-SA 3.0 (https://creative commons.org/licenses/by-sa/3.0)] Yeast (right): Microrao [Public domain]
Figure 5.3.3 - Mold (left) and yeast (right)

REVIEW QUESTIONS ?
1. A 24-year-old female presents to the physician • Correct answer: C
due to a cough and chest pain that began two • Findings suggestive of Histoplasma
days ago. She works at a pet store cleaning capsulatum:
bird cages. She also has smoked a pack of • A cough and chest pain which is
cigarettes per day for the past 8 years. Her suggestive of pneumonia
temperature is 38.8°C (101.8°F). A chest • She cleans bird cages
x-ray reveals parenchymal infiltrates and • Histopathological examination has
hilar lymphadenopathy. Histopathological revealed the presence of yeast-phase
examination of a mediastinal lymph node organisms inside of macrophage
reveals the presence of yeast-phase organisms • Histoplasma capsulatum also exhibits
inside of macrophages. What other pathological granuloma formation (an organized
finding is most likely present in this individual? collection of macrophages)
• A is a reference to hepatomegaly which
A. Enlarged hepatocytes
can be seen in patients with disseminated
B. Septate hyphae that branch at acute angles
C. An organized collection of macrophages histoplasmosis (this patient has a relatively
D. Spherules filled with endospores healthy immune system so it’s unlikely that
the fungus has disseminated)
• B is a reference to Aspergillus which is a
monomorphic fungus and forms septate
hyphae that branch at acute angles
• D is a reference to coccidioidomycosis
168
Section 2 - Blastomyces dermatitidis
1. Big blast: Blastomyces dermatitidis
2. Butterfly patch for the butterfly squad: dimorphic
(mold at 20°C and yeast at 37°C)
3. GPS showing central and eastern parts of the U.S.:
endemic to the central and eastern parts of the U.S.
4. Big lake: commonly seen in the Great Lakes area
5. Soldier coughing on smoke from the blast:
causes flu-like symptoms and pneumonia in
immunocompromised individuals
6. White flag with burn pattern resembling the lungs:
may cause chronic inflammation of the lungs
(chronic pneumonia)
7. Injured man on a stretcher with bones protruding
from skin: can disseminate to the bone and skin in
immunocompromised patients
8. Gray and black burn spots: can cause verrucous
skin lesions in immunocompromised patients (may
appear similar to squamous cell carcinoma)
9. Large bump on the stretcher: can cause
granulomatous nodule formation in
immunocompromised patients
10. Two grenades right next to each other: exhibits
broad-based budding
11. Soldier with a tattoo of his granny: associated with
granuloma formation
12. Granny wearing a shawl with the letter “A” on it:
treat local infections with azole medications (i.e.
itraconazole)
13. Amphibian on the soldier’s gun: treat systemic
infections with amphotericin B
 169

Photo Credit: Kelly Nelson (Photographer) [Public domain]

Figure 5.3.5 - Squamous cell carcinoma

Photo Credit: Alborz Fallah [CC BY-SA 3.0 (https://creativecommons.org/

licenses/by-sa/3.0)]
Figure 5.3.4 - Verrucous skin lesion
170

Photo Credit: [Public domain]

Figure 5.3.6 - Granulomatous nodule

Photo Credit: Medmyco at English Wikipedia [CC0]

Figure 5.3.7 - Broad-based budding by Blastomyces
dermatitidis

REVIEW QUESTIONS
1. A 23-year-old female with a history of HIV
presents to the physician due to a red sore on
her left arm. She states that she first noticed it
3 days ago but that it has been getting worse.
She has also had a cough for the past several
months but didn’t think much of it. She is not
compliant with antiretroviral therapy. Physical
examination reveals a violet-colored verrucous
lesion with irregular borders. A biopsy is
obtained and shown below.
Photo Credit: CDC [Public domain]
Which of the following is true regarding the
causal organism?
A. It may also cause osteomyelitis
B. It is endemic to the Southwestern U.S.
C. It is transmitted through bat droppings
D. Microscopy may also reveal septate hyphae
that branch at 45 degree angles
171
?
• Correct answer: A
• This patient has an infection caused by
Blastomyces dermatitidis
• The chronic cough is alluding to
pulmonary blastomycosis which is likely
around the time that the patient first
became infected
• Her history of HIV  is likely what allowed
the infection to disseminate to the skin
• She’s presenting with a disseminated
Blastomyces skin infection resulting
in the characteristic violet-colored
verrucous skin lesion
• This, along with the pathological
specimen showing broad-based
budding, is enough information to
conclude that the causal organism is
Blastomyces dermatitidis
• B is incorrect because this is describing the
geographic location of coccidioidomycosis
which does not exhibit broad-based
budding as seen in the picture
• C is incorrect because this is describing the
transmission of histoplasmosis which does
not exhibit broad-based budding
• D is incorrect because this is a reference to
the morphology of Aspergillus fumigatus
which does not exhibit broad-based
budding
172

Section 3 - Coccidioides immitis

1. Cocking a gun: Coccidioides immitis 13. Hammock that looks like a stretcher:
2. Picture of the Southwestern U.S. inscribed on gun: can disseminate to the skin and bone in
endemic to the Southwestern U.S. immunocompromised individuals
3. Butterfly on balloon: dimorphic 14. Man on hammock wearing a hat: can cause
4. Butterfly balloon is spherical-shaped: a mold form meningitis in immunocompromised individuals
at cold temperatures and a spherule (not yeast) at 15. Granny wearing a shawl with the letter “A” on it:
warm temperatures treat local infections with azole medications (eg,
5. Popped balloon releasing confetti and butterfly fluconazole, itraconazole)
balloon is larger than red balloon: the spherules 16. Desert amphibian underneath the hammock: treat
are much larger than RBCs and are filled with disseminated infections with amphotericin B
endospores
6. Silver bullet: can be identified using the silver stain
7. Bullets stirring up dust: transmission occurs via
inhalation of spores that are released from the soil
(eg, earthquakes, archeological excavations)
8. Shooting target: can cause erythema multiforme
(target-like lesions)
9. Dust causing the granny to cough: can cause
pneumonia
10. Granny here to support her son: associated with
granuloma formation
11. Red and injured elbow from bullet fragment: can
cause arthralgias
12. Remnants of ruptured balloons on the desert
ground: can cause erythema nodosum (desert Photo Credit: CDC [Public domain]

bumps) Figure 5.3.8 - Endospore of Coccidioides immitis

 173

REVIEW QUESTIONS ?
1. A 33-year-old female presents to her physician
due to shortness of breath, chest pain, and a
cough that has steadily worsened over the past
week. Her temperature is 38.7°C (101.7°F).
Physical examination reveals crackles at the
base of the lungs bilaterally. A pathological
specimen is obtained and shown below.

Photo Credit: CDC [Public domain]

Figure 5.3.9 - Coccidioides using the methenamine
silver stain

Photo Credit: CDC [Public domain]

Based on the information above, where does

this patient most likely live?
A. Ohio
B. Michigan
C. Nevada
D. Brasil

• Correct answer: C
• This patient has an infection caused by
Coccidioides immitis
• She has pneumonia (shortness of
breath, chest pain, a cough, a fever
of 38.7°C, and crackles heard on
Photo Credit: Grook Da Oger [CC BY-SA 3.0 (https://creativecommons.org/ examination)
licenses/by-sa/3.0)]
• The pathological specimen reveals a
Figure 5.3.10 - Erythema multiforme
spherule which is unique to Coccidioides
immitis
• A is the endemic location of histoplasmosis
• B is the endemic location of blastomycosis
• D is the location of paracoccidioidomycosis

Photo Credit: Medicalpal [CC BY-SA 4.0 (https://creativecommons.org/

licenses/by-sa/4.0)]
Figure 5.3.11 - Erythema nodosum
174
Section 4 - Paracoccidioides brasiliensis
1. Brazilian embassy: Paracoccidioides brasiliensis
2. Captain South America’s wheel-shaped shield:
budding yeast may exhibit a “captain wheel”
appearance
3. Image of South America on the shirt of Captain
South America: endemic to Latin America
4. Butterfly-like aliens attacking: dimorphic (mold at
20°C and yeast at 37°C)
5. Granny hostage: associated with granuloma
formation
6. Granny coughing: causes a pulmonary infection
(often asymptomatic)
7. Injured civilian on a stretcher: immunocompromised
individuals are at risk of developing disseminated
disease
8. Liver-shaped spot on dalmatian service dog: causes
hepatosplenomegaly
9. Beaded net full of medical supplies: causes
lymphadenopathy
10. Granny wearing a shawl with an “A” on it: treat local
infections with azole medications (eg, itraconazole,
voriconazole)
11. Amphibians jumping near the civilian on
the stretcher: treat systemic infections with
amphotericin B
 175

REVIEW QUESTIONS ?
1. A 27-year-old male with a history of HIV
presents to the physician due to swollen bumps
in his neck, armpits, and groin that began 2
days ago. He states that he just returned home
from a trip to South America and is worried he
may have contracted an illness while traveling.
His temperature is 38.9°C (102.0°F). Physical
examination reveals lymphadenopathy and
hepatosplenomegaly. Microscopic visualization
of which of the following will most likely be
Photo Credit: CDC/Dr. Lucille K. Georg [Public domain]
present in a tissue sample taken from this
Figure 5.3.12 - Budding cells of Paracoccidioides
patient?  
brasiliensis
A. Broad-based budding
B. Spherules filled with endospores
C. Macrophages filled with fungi
D. Budding yeast protruding from a ring-like
structure

• Correct answer: D
• The patient has an infection caused by
Paracoccidioides brasiliensis
• He has a compromised immune system
(eg, HIV)
• He recently traveled to South America
• He is presenting with lymphadenopathy
and hepatosplenomegaly
• Paracoccidioides brasiliensis exhibits
a microscopic “captain’s wheel”
appearance which may be described as
budding yeast protruding from a ring-
like structure
• A is incorrect because this is describing
Blastomyces but this is not endemic to
South America
• B is incorrect because this is describing
coccidioidomycosis which is endemic to the
Southwestern U.S.
• C is incorrect because this is describing
histoplasmosis which is endemic to the
Mississippi and Ohio River valleys
176
Section 5 - Microsporum, Trichophyton, and Epidermophyton
1. Dermatologists fighting: dermatophytes
2. Image of the epidermis: Epidermophyton
3. Microscope: Microsporum
4. A child’s “trike”: Trichophyton
5. Dermatologist receiving a “K.O.” punch causing him
to knock over a little plant with branches and fruit:
a KOH preparation will reveal branching septate
hyphae (and possibly spores)
6. A patient holding a baseball cap: Tinea capitis
7. Bald patches on baseball coach: Tinea capitis is
associated with alopecia
8. Beaded net holding baseballs: Tinea capitis is
associated with lymphadenopathy
9. Baseball coach’s son reading a book about dragons:
Tinea capitis is associated with scaling
10. Marine Corps tattoo: Tinea corporis
11. Marine Corps tattoo on the torso: Tinea corporis
lesions are commonly seen on the torso
12. Red Marine Corps tattoo with a white center: the
rash is characterized by an erythematous scaly ring
with a central area of clearing
13. Marine Corps patient holding his two pets: Tinea
corporis can be acquired by infected animals (eg,
pets, farm animals)
14. Athlete with infected foot: Tinea pedis (athlete’s
foot)
15. Athlete’s moccasins on nearby table: moccasin-type
tinea pedis
16. Fruit splattered on athlete’s foot: vesiculobullous
tinea pedis
17. Intertwined fingers with champion rings: interdigital
tinea pedis
18. Worker nailing up decorations: Tinea unguium
is a fungus that causes infection of the nail
(onychomycosis)
19. Image of little girl’s bathing suit getting tugged on
by a dog: Tinea cruris (jock itch) is a dermatophyte
infection that occurs in the inguinal area
20. Dermatologist wearing a shawl with an “A” on it:
most dermatophyte infections should be treated
with topical azoles
21. Worker applying grease to the window: griseofulvin
can be used to treat dermatophyte onychomycosis
22. Worker wearing a turban: terbinafine can be used to
treat dermatophyte onychomycosis
 177

Photo Credit: CDC/Dr. Lucille K. George [Public domain]

Figure 5.3.13 - Hyphae and spores of a
dermatophyte

Photo Credit: Teresa Trimm [Flickr]

Figure 5.3.16 - Tinea pedis

Photo Credit: myself [CC BY-SA 4.0 (https://creativecommons.org/licenses/

by-sa/4.0)]
Figure 5.3.14 - Tinea capitis

Photo Credit: Soodleksw [Public domain]

Figure 5.3.17 - Vesicular athlete’s foot
Photo Credit: Corina G. [Public domain]
Figure 5.3.15 - Tinea corporis
178

Photo Credit: Robertgascoin [CC BY-SA 3.0 (https://creativecommons.org/

licenses/by-sa/3.0)]
Photo Credit: User Falloonb on en.wikipedia [Public domain]
Figure 5.3.20 - Tinea cruris
Figure 5.3.18 - Interdigital tinea pedis

Photo Credit: Medical334 [CC BY-SA 4.0 (https://creativecommons.org/

licenses/by-sa/4.0)]
Figure 5.3.19 - Onychomycosis
 179

REVIEW QUESTIONS ?
1. A 17-year-old male presents to the physician
due to a pruritic rash on his leg that he noticed
yesterday. He is on the high school football
team and states that he sweats excessively
during practices. Physical examination reveals
an erythematous scaling patch on the medial
aspect of the left inner thigh. Scales are scraped
from the lesion and a potassium hydroxide
(KOH) preparation reveals branching septate
hyphae. This patient’s condition is best treated
with which of the following medications?
A. Selenium sulfide
B. Amphotericin B
C. Fluconazole
D. Nystatin

• Correct answer: C
• This patient has tinea cruris (jock itch)
• An erythematous scaling patch on the
medial aspect of the left inner thigh
• A pathological sample revealed
branching septate hyphae from a KOH
prep
• The treatment for jock itch is
fluconazole
• A is incorrect because this is the treatment
for malassezia furfur
• B is the treatment for several severe fungal
infections such as systemic histoplasmosis
and blastomycosis
• D is true of infections caused by
Candida such as oral thrush or vaingal
candidiasis but this is not effective against
dermatophyte infections
180
Section 6 - Malassezia furfur
1. Malodorous and furry armpits: Malassezia furfur
2. Armpits: causes pityriasis versicolor
3. “Summer Special” sign and margarita: more
common in the summer when it’s hot and humid
(the yeast is converted into the pathogenic mycelial
form under these conditions)
4. Greasy hands squeezing lemon acid onto a melon:
the degradation of lipids produces acids that inhibit
melanin synthesis
5. Scratching her head in awe: results in pruritic lesions
6. Black and white, checkered shirt: the rash is
characterized by areas of hyperpigmentation and
hypopigmentation (pink patches may also be seen)
7. Spaghetti and meatballs: may exhibit a “spaghetti
and meatballs” appearance on microscopy
8. “FOR SALE” on the menu: treat with topical
selenium sulfide
9. A shawl with the letter “A” on it: treat extensive
disease with oral azole medications
 181

REVIEW QUESTIONS ?
1. A 24-year-old female presents to the physician
due to a pruritic rash which she noticed several
weeks ago. Physical examination reveals
a rash on the patient’s trunk with areas of
hypopigmentation and hyperpigmentation. A
sample of tissue is obtained and a potassium
hydroxide (KOH) preparation reveals the
presence of both yeast cells and hyphae.
Which of the following risk factors is most likely
associated with this patient’s condition?
 
Photo Credit: Saracrosenau on Flickr.com [CC BY-SA 2.0 (https:// A. Chronic alcohol use
creativecommons.org/licenses/by-sa/2.0)] B. Poor hygiene
Figure 5.3.21 - Tinea versicolor skin lesions C. Hyperhidrosis
D. Recent exposure to antibiotics

• Correct answer: C
• This patient has a Malassezia furfur
infection
• A pruritic rash with areas
of hypopigmentation and
hyperpigmentation
• KOH prep has revealed both yeast cells
and hyphae is describing the “spaghetti
and meatballs” appearance of the
organism
• This infection is more common in the
Photo Credit: CDC/Dr. Lucille K. Georg [Public domain] summer when the weather is hot and
Figure 5.3.22 - Microscopic image of Malassezia humid or under similar conditions (eg,
furfur “Spaghetti and meatballs” hyperhidrosis leading to hot and humid
conditions)
• Under hot and humid conditions,
the yeast form is converted to the
pathogenic mycelial form which can
cause disease.
• A, B, and D are not known risk factors for
developing tinea versicolor
• A and B are red herrings and D is often
associated with Candida albicans but not
Malassezia furfur
182
Section 7 - Sporothrix schenckii
1. Prison shank: Sporothrix schenckii
2. Branch with thorns: lives on vegetation and is
transmitted through thorn pricks
3. Butterfly tattoo: dimorphic (mold at 20°C and yeast
at 37°C)
4. Cigar: exhibits cigar-shaped budding in the yeast
form
5. Plants with branches and fruit: exhibits branching
hyphae with rosettes of conidia in the mold form
6. Linear skin scrape: presents as erythematous lesions
along draining lymphatics that later ulcerate
7. Injured prisoner on a stretcher: disseminated
disease is possible in an immunocompromised host
8. Pot plants: treat with potassium iodide
9. Shawl with an “A” on it: treat with azole medications
(i.e. itraconazole)
 183

REVIEW QUESTIONS ?
1. A 27-year-old female presents to the physician
due to a rash on her leg. She states that she first
noticed the rash two days ago after working in
her garden. Physical examination reveals mildly
tender erythematous papules extending from
the ankle up to the knee. A tissue sample is
obtained and viewed under the microscope.
What morphological feature will most likely be
seen?
Photo Credit: CDC/Dr. Lucille K. Georg [Public domain] A. Branching hyphae with terminal conidia
Figure 5.3.23 - Sporothrix schenckii (yeast form) B. Elongated oval-shaped yeast cells
  C. Spherules filled with endospores
D. Budding yeast that resemble a “captain’s
wheel”

• Correct answer: B
• The patient has a Sporothrix schenckii
infection
• Developed a rash on her leg after
working in the garden (exposed to
thorns)
• Has mildly tender erythematous
papules from the ankle up to the knee
(lesions draining along lymphatic
Photo Credit: CDC/Dr. Libero Ajello [Public domain] channels)
Figure 5.3.24 - Sporothrix schenckii (mold form) • Elongated oval-shaped yeast cells is
describing cigar-shaped budding
• A is wrong because this is describing the
mold form of Sporothrix schenckii (the mold
form is seen outside of the human body but
not in the warmer environment within a
host)
• C is incorrect because this is describing the
morphology of coccidioidomycosis
• D is a reference to paracoccidioidomycosis
which is unlikely to cause lesions after
gardening

Photo Credit: CDC/Dr. Lucille K. Georg [Public domain]

Figure 5.3.25 - Sporothrix schenckii lesion along
draining lymphatic channels
184
Section 8 - Candida albicans
1. Canadian flag: Candida albicans
2. Building a snowman out of cotton: reproduces
through budding
3. Butterfly: dimorphic
4. Fruit tree with branches near cold window with
icicles: forms pseudohyphae and budding yeast at
20°C
5. Drinking hot coffee through straw: germ tube
formation at 37°C
6. Flowers: part of the normal flora (eg, mouth, skin,
vagina, intestines)
7. Cat: catalase positive
8. Worker with Band-Aid is eating cotton balls on a
conveyor belt with a sign reading “Max rate = 200”:
causes oral thrush in immunocompromised patients
(an AIDS patient with a CD4 count < 200)
9. Scraping cotton balls off the mat: the lesions in oral
thrush can be easily scraped off
10. Cotton balls traveling down the conveyor belt with
a “Max rate = 200” sign: causes esophagitis in AIDS
patients with a CD4 count < 200
11. A shawl with an “A” on it: oral and esophageal
candida infections can be treated with azoles
12. Bag of Funyuns: oral and esophageal candida
infections can be treated with echinocandins
13. Nice boss with a picture of Satan on shirt: oral and
esophageal candida infections can be treated with
nystatin
14. A girl with dyed beads and a container of pills
who has spilled cotton onto her crotch: causes
vulvovaginitis (especially in patients with diabetes
or those who are taking antibiotics)
15. Cotton appearing like thick clumps of cottage
cheese: thick “cottage cheese” discharge
16. Tub of acid with a pH in the range of 4.0 - 4.5: the
vaginal pH will be normal (4.0 - 4.5)
17. A shawl with an “A” on it: candida infections causing
vulvovaginitis can be treated with azoles
18. Cotton spilled onto baby’s red diaper: can cause an
erythematous diaper rash in children
19. Little toy car: can cause endocarditis in IV drug users
20. Boss with a Canadian flag tattoo salivating over
his food: associated with chronic mucocutaneous
candidiasis (an immunodeficiency)
21. Fish with scales: can cause osteomyelitis
22. Tubes bursting off machine: patients receiving
parenteral nutrition through a catheter may develop
candidemia
23. Wall blasted with a uniquely-shaped dent:
neutropenic patients are at an increased risk of
developing disseminated disease
 185

24. Worker receiving a “K.O.” blast from the machine: a

KOH preparation can be used to identify candida
25. Pet amphibian jumping around machine:
amphotericin B can be used to treat systemic
infections
26. Girl with “A” shawl and bag of Funyuns near the
exploding machine: echinocandins followed by an
oral azole medication can also be used for systemic
infections

Photo Credit: Y tambe [CC BY-SA 3.0 (https://creativecommons.org/licenses/

by-sa/3.0)]
Figure 5.3.26 - Pseudohyphae and budding yeast

Photo Credit: CDC/Dr. Lucille K. Georg [Public domain]

Figure 5.3.27 - Germ tube formation
186

Photo Credit: Mikael Häggström [CC0]

Figure 5.3.30 - Vulvovaginitis caused by Candida
Photo Credit: James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.
albicans
org/licenses/by-sa/3.0)]
Figure 5.3.28 - Oral thrush

Photo Credit: James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.

org/licenses/by-sa/3.0)]
Figure 5.3.29 - Esophageal candidiasis
 187

REVIEW QUESTIONS ?
1. A 33-year-old female is found to have chills
and a persistent fever 3 days after undergoing
extensive excision of metastatic breast cancer.
Her temperature is 38.7°C (101.7°F). Physical
examination reveals a well-placed central
venous catheter through which she is receiving
parenteral nutrition. Blood cultures are
obtained and reveal budding yeast. Which of
the following is true regarding the most likely
causal organism?
A. It will exhibit “germ tubes” at 20°C
B. It is part of the normal skin flora
C. It is catalase-negative
D. It is monomorphic

• Correct answer: B
• This patient has candidemia
• She is receiving parenteral nutrition
through a central venous catheter
• Blood cultures have shown budding
yeast
• Candida is part of the normal skin flora
• A is wrong because Candida exhibits germ
tubes at 37°C
• C is wrong because Candida is catalase-
positive
• D is wrong because Candida is dimorphic
188
Section 9 - Aspergillus fumigatus
1. Asparagus jungle: Aspergillus fumigatus
2. Branches and chop mark: hyphae branch at 45
degree angles (V-shaped) and have septations
3. Cat: catalase positive
4. Man on stretcher near blast: cause invasive disease
in immunocompromised patients
5. 100 dollar bill Band-Aid: invasive disease seen in
AIDS patients with a CD4 count <100
6. Commando grandpa: invasive disease may be seen
in patients with neutrophil dysfunction (eg, chronic
granulomatous disease)
7. Hope ribbon covered in blood: invasive disease may
be seen in patients with leukemia
8. Medic with lamp and cough: invasive pulmonary
disease may present with a fever and cough
9. Medic coughing up blood and holding chest:
invasive pulmonary disease may present with chest
pain and hemoptysis
10. “Vietnam this way” sign: invasive disease may
present as fungal rhinosinusitis (similar to Mucor
and Rhizopus spp.)
11. Women wearing “A” shawls: treat local and invasive
disease with azoles (eg, voriconazole)
12. Funyuns: invasive disease can be treated with
echinocandins
13. Crater with asparagus and tubers: can cause
aspergillomas which form due to fungal colonization
of old lung cavities (eg, following a TB infection)
14. Red beet juice: aspergillomas may cause hemoptysis
15. Sweaty skinny guy: secondary TB presents with
night sweats and weight loss (patients with an
aspergilloma have an absence of these symptoms)
16. Aflac life insurance guy with iconic duck: some
species produce aflatoxins
17. Duck eating nuts and grains in bowl: aflatoxins can
be found in grains and nuts
18. Dog with liver shaped spot: aflatoxins are associated
with hepatocellular carcinoma
19. Coughing soldiers with inhaler and bag of salt:
allergic bronchopulmonary aspergillosis (ABPA) is a
hypersensitivity response that occurs when fungus
colonizes the bronchial mucosa of asthmatics or CF
patients
20. Whittling soldier: allergic bronchopulmonary
aspergillosis (ABPA) may cause bronchiectasis
21. Red circular debris: allergic bronchopulmonary
aspergillosis (ABPA) is associated with eosinophilia
 189

REVIEW QUESTIONS ?
1. A 59-year-old male is brought to the emergency
department due to a cough and bloody sputum.
He states that he has had a cough for the
past few days, but only noticed the blood this
morning. He has a history of tuberculosis (TB)
that was successfully treated several years ago.
He denies recent night sweats, fevers, or weight
loss. Imaging is obtained and shown below.
This patient’s condition is most likely caused by
Photo Credit: CDC [Public domain] which of the following?
Figure 5.3.31 - Microscopic morphology of
Aspergillus fumigatus

Stockholm [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-

sa/4.0)]

A. A hypersensitivity reaction
Photo Credit: Yale Rosen from USA [CC BY-SA 2.0 (https://creativecommons.
org/licenses/by-sa/2.0)] B. Reactivation of a latent organism
Figure 5.3.32 - Aspergilloma (gross image) C. Invasive fungal disease involving the
vasculature
D. Fungal colonization of a prior lesion
E. Pulmonary invasion by neoplastic cells

• Correct answer: D
• This patient has an aspergilloma
• Cough, hemoptysis (bloody sputum),
and a history of TB
• Imaging has shown an aspergilloma
• An aspergilloma is Aspergillus fumigatus
colonization of a prior cavitary TB lesion
• A is describing allergic bronchopulmonary
aspergillosis
• B is describing reactivation TB which
Photo Credit: Stockholm [CC BY-SA 4.0 (https://creativecommons.org/ presents with night sweats, fevers, and
licenses/by-sa/4.0)]
weight loss which this patient does not have
Figure 5.3.33 - Aspergilloma (imaging)
• C is describing invasive aspergillosis
(presents in severely neutropenic and
immunocompromised patients and presents
with a cough, hemoptysis, fevers, and chest
pain)
190
Section 10 - Cryptococcus neoformans
1. Crypt: Cryptococcus neoformans
2. Orbs on staff separated by a narrow stock: exhibits
narrow-based budding
3. 5-10 micrometers: 5-10 micrometers
4. Ink drawing of angel: can be identified using
the India ink stain which will show a clear halo
surrounding the pathogen
5. Pigeon and droppings: found in soil and pigeon
droppings
6. Dust: acquired through inhalation
7. Pool of urine: urease positive
8. “Keep the Sabbath day holy”: can be grown on
Sabouraud dextrose agar
9. Red sack and music: can be identified using the
mucicarmine stain which reveals a red capsule
10. Latex gloves: the latex agglutination test can be
used to identify the polysaccharide capsular antigen
(more specific and sensitive than other tests)
11. “50-year-old male” with Band-Aid: causes disease in
immunocompromised patients (AIDS patients with a
CD4 count less than 50)
12. Cough: the primary site of infection is in the lungs
(most patients are asymptomatic)
13. Religious hat: can cause meningitis
14. Urine dripping on head: can cause encephalitis
15. Soap bubbles: imaging may reveal “soap bubble”
lesions in the brain
16. Flute and sai: treat with flucytosine
17. Shawl with letter “A”: treat cryptococcal meningitis
with azoles (fluconazole)
18. Amphibian drawing: treat cryptococcal meningitis
with amphotericin B
 191

REVIEW QUESTIONS ?
1. A 50-year-old female with a history of HIV is
brought to the emergency department by her
husband due to sudden onset confusion. He
states that this morning she got lost driving her
car and had difficulty remembering the year.
Her temperature is 38.8°C (101.8°F). Physical
examination reveals nuchal rigidity. A lumbar
puncture is performed and cerebrospinal fluid
is sent to the laboratory for further analysis. A
latex agglutination test is positive. This patient’s
Photo Credit: CDD/Dr. Leanor Haley [Public domain] neurological findings most likely occurred
Figure 5.3.34 - India ink stain following hematogenous dissemination from
which of the following regions?
A. Skin
B. Nares
C. Lungs
D. Ear canal
E. Urinary tract

• Correct answer: C
• This patient has meningitis caused by
Cryptococcus neoformans
• HIV, sudden onset confusion, a fever of
38.8°C, and a positive agglutination test
• The organism is acquired through
Photo Credit: CDD/Dr. William Kaplan [Public domain]
inhalation
Figure 5.3.35 - Sabouraud dextrose agar • Cryptococcus neoformans can cause
lung infections and this is the primary
site of infection before hematogenous
spread occurs
• Many bacterial pathogens can cause
meningitis and can disseminate from the
nares (B) or other locations (A, D, and E),
but these would not have a positive latex
agglutination test

Photo Credit: CDD/Dr. Edwin P. Ewing, Jr. [Public domain]

Figure 5.3.36 - Mucicarmine stain
192
Section 11 - Mucor & Rhizopus spp.
1. Rising zombie: Mucor & Rhizopus species
2. Inhaling smell from snails: transmitted via inhalation
of spores
3. Sorcerer’s broad-angled stance: exhibit irregular,
broad, and nonseptate hyphae that branch at wide
angles
4. Dyed beads: diabetic ketoacidosis is a risk factor
5. Tombstones: neutropenia is a risk factor
6. Zombie with hope ribbon: leukemia is a risk factor
7. Deformed face: can cause facial infections resulting
in necrotic eschar
8. Hand on head: may present with headache and
facial pain
9. Eye: there may be orbital involvement
10. Witches hair: may cause cranial nerve damage
11. Red lava cracks: proliferate in blood vessel walls
12. Cave with signs: cavernous sinus thrombosis
13. “CRIPS” graffiti: can penetrate the cribriform plate
14. Flowers covered in lava: can disseminate to the
brain and cause rhinocerebral abscesses as well as
frontal lobe abscesses
15. Cutting out the oral mucosa: mucosal biopsy
confirms the diagnosis
16. Scalpel: treatment includes surgical debridement of
infected tissue
17. Shawl with letter “A”: treat with azoles
18. Amphibians: treat with amphotericin B
 193

Photo Credit: Mucormycosis by Yale Rosen via Flickr.com

Figure 5.3.37 - Microscopy of mucormycosis

REVIEW QUESTIONS ?
1. A 7-year-old girl who is undergoing • C is true of deficits involving the temporal
chemotherapy for acute lymphoblastic leukemia lobe, but the frontal lobe is more commonly
is brought to the emergency department due affected with these types of infections
to a fever and right eye pain. Her father states • D is true of deficits involving the parietal
that the pain began two days ago, but several lobe (location of the primary sensory
hours ago she was unable to close her right cortex)
eye. Physical examination reveals periorbital
tenderness, hyperacusis, and an inability to
close the right eye lid. This patient is most likely
at risk for developing which of the following?
A. Diabetic ketoacidosis
B. Paralysis of the left arm
C. Wernicke’s aphasia
D. Decreased sensation over the left foot

• Correct answer: B
• This patient has a facial nerve deficit caused
by Mucor & Rhizopus spp.
• She has leukemia, a fever, and eye pain
• The inability to close the right eye along
with hyperacusis is suggestive of a facial
nerve deficit
• Mucor & Rhizopus spp. can also cause
a frontal lobe abscess and the primary
motor cortex is located in the frontal
lobe → contralateral paralysis
• A is incorrect because a Mucor & Rhizopus
spp. infection doesn’t increase her risk of
diabetic ketoacidosis (DKA increases the risk
of an infection)
194
Section 12 - Pneumocystis jirovecii
1. Hero: Pneumocystis jiroveci
2. Yeast beer: a yeast-like fungus
3. Plate: exhibits disc-shaped cysts that can be
identified using the methenamine silver stain
4. Happy thugs: most infections are asymptomatic
5. Man on stretcher: most patients who develop
symptoms are immunocompromised
6. Bag of Band-Aids and “Max Occupancy 200”: AIDS
patients with a CD4 count <200 are at an increased
risk of disease (start prophylactic treatment at this
CD4 count)
7. Axe and broken glass: causes interstitial pneumonia
with ground glass opacities seen on chest imaging
8. Red spots on lungs: imaging may reveal
pneumatoceles
9. Water spraying axe: can be diagnosed by lung biopsy
or bronchoalveolar lavage
10. 3-pronged chain: can be diagnosed with PCR
11. Fiery arrow: diagnosed with a fluorescent antibody
stain
12. Crystal meth: first-line treatment and prophylaxis is
TMP-SMX (give when CD4 count drops <200)
13. Deputy: an alternative prophylactic medication is
dapsone
14. Pentagonal sign: an alternative prophylactic
medication is pentamidine
15. Ice-cream cone on toe: an alternative prophylactic
medication is atovaquone
 195

Photo Credit: CDC/Dr. Russell K. Brynes [Public domain] Photo Credit: CDC/Dr. Govinda S. Visvesvara [Public domain]
Figure 5.3.38 - Silver stain of Pneumocystis jirovecii Figure 5.3.41 - Fluorescent antibody stain
cysts

Photo Credit: Carolyn M. Allen, Hamdan H. AL-Jahdali, Klaus L. Irion, Sarah Al Ghanem, Alaa Gouda, and Ali Nawaz Khan [CC BY 4.0 (https://creativecommons.
org/licenses/by/4.0)]
Figure 5.3.39 - Chest x-rays of Pneumocystis pneumonia with “ground glass” opacities

Photo Credit: Carolyn M. Allen, Hamdan H. AL-Jahdali, Klaus L. Irion,

Sarah Al Ghanem, Alaa Gouda, and Ali Nawaz Khan [CC BY 4.0 (https://
creativecommons.org/licenses/by/4.0)]
Figure 5.3.40 - Pneumatoceles
196

REVIEW QUESTIONS
1. A 27-year-old male comes to the emergency
department due to a cough and shortness
of breath. He states that the cough has been
present for one week, but the shortness of
breath began earlier today. He has a history
of HIV and has been non-compliant with
antiretroviral therapy. A bronchoalveolar lavage
is performed and a silver stain of the sample is
shown below.
?
• Correct answer: C
• This patient has a Pneumocystis jirovecii
infection
• He has a cough, shortness of breath,
and a history of HIV
• The silver stain shows cysts that
resemble yeast cells
• Pneumocystis jirovecii can cause
pneumatoceles (cystic air-filled lesions
in the lungs)
• A is wrong because TMP-SMX prophylaxis is
given when the CD4 count drops to below <
200
• B is wrong because most infections
asymptomatic and do not actually cause
pneumonia
• D is wrong because this is a medication used
for malaria

Photo Credit: CDC/ Dr. Edwin P. Ewing, Jr. [Public domain]

Which of the following is most like true

regarding this patient’s condition?
A. TMP-SMX prophylaxis should be started
when the CD4 count drops to < 500 cells/
mm 3

B. Most infections by the causal organism

result in interstitial pneumonia
C. Cystic air-filled lesions in the lungs may be
seen on imaging
D. An alternative prophylactic medication is
chloroquine
 197

PARASITES

Figure 5.4.1 - Parasites overview figure

198

Section 1 - Giardia lamblia

1. “Guard A Lamb”: Giardia lamblia 6. Brown river: causes diarrhea

2. Cysts in pool: cysts found in stool
3. Drinking poo water: fecal-oral transmission
4. Parasites in water: cysts develop into trophozoites
5. Man catching parasites: diagnose with stool
examination test (O and P test) which will reveal
cysts or trophozoites
7. Camper: common in campers and hikers
8. Stink lines: foul-smelling diarrhea
9. Man holding stomach: causes abdominal pain
10. Bloated man: causes bloating
11. Protein drink: Giardia lamblia is a protozoan
12. Metro: treat with metronidazole

REVIEW QUESTIONS
1. A 23-year-old female presents to the clinic
Photo Credit: Public domain
Figure 5.4.2 - Giardia lamblia cyst
Photo Credit: schmidty4112 via Flickr
Figure 5.4.3 - Giardia lamblia trophozoite
199
?
with abdominal pain for two weeks. She
explains that her symptoms began shortly
after returning from a short camping trip near
a lake. She denies intentionally drinking any
of the lake water, but admits she accidentally
swallowed quite a bit one time while swimming.
The physician orders an ova and parasite
examination (O & P) of the stool. The laboratory
confirms the presence of several pear-shaped,
flagellated trophozoites. Based on the likely
pathogen, which of the following is the patient
most likely to experience at some point during
her infection?
A. A short period of vomiting
B. Blood in the stool
C. Repeated bouts of loose stools
D. Painful headaches
• Correct answer: C
• The patient likely has giardiasis based
on the following:
• Abdominal pain
• Recent camping
• Drinking lake water
• O & P revealing pear-shaped
flagellated trophozoites
• Giardiasis is most likely to cause
diarrhea
• Choice A is incorrect because vomiting is
much less likely than diarrhea
• Choice B is incorrect because giardiasis does
not cause intestinal bleeding
• Choice D is incorrect because giardiasis is
not known to cause headaches
200
Section 2 - Entamoeba histolytica
1. “Enter My History”: Entamoeba histolytica
2. Red people inside monster: red blood cells seen in
trophozoite cytoplasm (erythrophagocytosis)
3. Protein shake: protozoa
4. Water supply drops eggs on poop: fecal-oral
transmission
5. Monster footprints ulcerating the ground: causes
intestinal ulcers
6. Hot lava river: causes bloody diarrhea
7. Stream reaching liver-spotted cows: trophozoites
travel up the portal vein to infect the liver
8. Melting cow: trophozoites cause liver abscesses
9. Ray’s descending on cows: diagnose liver abscesses
with CT scan
10. Gems in blood and stool vials: diagnose via antigens
in stool or blood
11. Cyst on spaceship: diagnose via stool examination
(O and P) which will reveal cysts
12. Metro: treat with metronidazole
13. Idol queen: treat with iodoquinol
14. Pair of mice: treat with paromomycin
15. Dropping Boiling water on monster: prevent
infection by boiling water before drinking

Photo Credit: CDC [Public domain]
Figure 5.4.4 - Red blood cells within Entamoeba
cytoplasm (erythrophagocytosis)
Photo Credit: CDC [Public domain]
Figure 5.4.5 - Entamoeba egg in stool sample
REVIEW QUESTIONS
1. A 22-year-old female presents to her family
physician for a fever and red diarrhea that
began one week ago. She recently returned
from a 3-week humanitarian trip to Kenya. She
endorses drinking water that did not undergo
filtering, heating or any other measures to
ensure water cleanliness. Physical examination
is significant for right upper quadrant abdominal
tenderness. An ova and parasite study of her
stool is examined. A micrograph of the test is
shown below. Which of the following is true
about her infection?
Photo Credit: CDC/Dr. George Healy [Public domain]
A. Her right upper quadrant pain is due to
infection of the biliary tree
B. Colonoscopy would reveal areas of damage
to the entire mucosal layer
C. Parasitic antigens will not be found in the
patient’s serum
D. An abdominal CT scan does not have a
diagnostic role this late in her workup
201
?
• Correct answer: B
• The patient likely has an infection with
Entamoeba histolytica based on the
following:
• Bloody diarrhea
• Drinking unclean water
• RUQ pain
• O & P micrograph revealing
a protozoan containing RBCs
(erythrophagocytosis)
• Entamoeba histolytica causes intestinal
ulceration (damage to the entire
mucosa)
• Choice A is incorrect because Entamoeba
histolytica infects the liver, not the biliary
tree
• Choice C is incorrect because antigens can
be found in the stool or the serum
• Choice D is incorrect because her RUQ pain
may be caused by hepatic abscess, making
abdominal CT scan necessary
202
Section 3 - Cryptosporidium
1. Crypts: Cryptosporidium
2. Hardened crypts releasing spores: cysts release
sporozoites
3. Growing appendages: sporozoites invade and
replicate within the gastrointestinal epithelium
4. Infected man entering crypt and saying, “Uh-oh”:
new oocytes form following replication
5. Hard coffin flowing down river: new oocysts are
shed in the stool
6. Injured man in stretcher: immunocompromised
patients demonstrate symptoms
7. Band-aid on injured man: AIDS patients at risk
8. 100 mph: AIDS patients susceptible when CD4
counts fall below 100
9. Vomiting man: infection can cause vomiting
10. River: infection can cause diarrhea
11. Protein drink: protozoa
12. Scientist scooping dirt at river’s edge: diagnose with
biopsy of intestinal epithelium
13. River gems: diagnose with stool antigen testing
14. Exploding acid: diagnose with acid fast stain from
stool sample
15. Nydus worm: treat with nitazoxanide
16. Pair of mice: can treat with paromomycin
17. Steel grate: prevent infection by filtering water
 203

REVIEW QUESTIONS
1. A 29-year-old man with stabilized and
Photo Credit: CDC [Public domain]
Figure 5.4.6 - Cryptosporidium oocysts with acid-
fast staining
?
medicated HIV presents for a routine follow-up
visit. The patient (patient A) endorses feeling in
good health and does not have any concerns.
Blood tests were ordered, revealing a CD4+
T-cell count of 1,100 cells/mm3, unchanged
from the previous visit. The physician also
treats the patient’s life partner (patient B) who
also has AIDS. Last week, the physician treated
patient B for a Cryptosporidium infection.
Patient A and patient B both drink from the
same water source. Regarding patient A, which
of the following is most likely true?
A. He is likely to experience diarrhea soon
B. Prophylactic nitazoxanide is warranted
C. Unprotected intercourse will increase
Cryptosporidium risk
D. He may have ingested oocysts from the
same water source

• Correct answer: D
• Patient A likely drinks from the same
water source as patient B, making
ingestion of oocysts possible
• Choice A is incorrect because patient A is
not immunocompromised
• Choice B is incorrect because nitazoxanide
is not warranted in immunocompetent
patients
• Choice C is incorrect because
Cryptosporidium is not sexually transmitted
204
Section 4 - Toxoplasma gondii
1. Toxic symbol: Toxoplasma gondii
2. Feline stepping in feces: transmission via cat feces
3. Examining fresh blood: diagnosed using serology
4. Hero eating cat’s encysted meat: transmitted via
consumption of cysts in meat
5. Torch: TORCHES infection
6. Crossing force field: can cross the placenta
7. Flames reflecting off of glasses: causes
chorioretinitis
8. Milk on feline’s head: can cause intracranial
calcifications
9. Blocked hose: can cause hydrocephalus
10. Ringed hand on brain of patient with band-aid:
causes ring-enhancing lesions in AIDS patients
11. 100 dollar bill: ring-enhancing lesions occur when
CD4+ cells are < 100.
12. Pulling on collar: causes pharyngitis in
immunocompetent patients
13. Heat lamps: causes fever in immunocompetent
patients
14. Tired from running: causes fatigue in
immunocompetent patients
15. Arrows that look the same: no heterophile
antibodies
16. Broken spotlight: monospot negative
17. Pirate meth: treat with pyrimethamine
18. Sulfur dice: treat with sulfadiazine
 205

REVIEW QUESTIONS
1. A 24-year-old G2P1 female presents at 17-weeks
Photo Credit: Aimun AB Jamjoo, Abrar R. Waliuddin, and Abdulhakim B.
Jamjoom [CC BY 2.5 (https://creativecommons.org/licenses/by/2.5/)]
?
gestation with a fever, sore throat and fatigue.
She describes her fatigue as different than
the fatigue she experienced with her previous
pregnancy. She feels healthy otherwise and
does not have a history of HIV exposure. Blood
work is drawn and sent to the laboratory for
analysis. Test results reveal antibodies produced
against a parasite often spread by cysts found in
cat feces. Which of the following is true about
her infection?
A. Her blood would agglutinate if exposed to
sheep serum
B. The parasite may cause retinal inflammation
of the fetus
C. She is at risk for the development of brain
lesions
D. Sulfadiazine and pyrimethamine should be
withheld

• Correct answer: B
• The patient likely has a Toxoplasma
gondii infection based on the following:
• Parasitic cysts often spread by cat
feces
• Fever, pharyngitis, fatigue
• Toxoplasma gondii can cause fetal
chorioretinitis
• Choice A is incorrect. Although
toxoplasmosis causes symptoms similar
to mononucleosis (EBV), it would be
heterophile (monospot) negative
• Choice C is incorrect because ring-enhancing
brain lesions only occur in AIDS patients
when the CD4+ T-cell count falls below 100
cells/mm3
• Choice D is incorrect because sulfadiazine
and pyrimethamine should be administered
to prevent congenital toxoplasmosis
206

Section 5 - Naegleria fowleri

1. Niagara falls: Naegleria fowleri
2. Protein shake shop: protozoa
3. Amoeba: exists in amoeba form only
4. Amoeba attacking nose: amoebas travel through the
cribriform plate to infect the CNS
5. Amoeba attacking head: causes
meningoencephalitis
6. Zombie-like victims: causes neck stiffness and
vomiting
7. Dead victims: CNS infection is lethal
8. Amphibians on dead bodies: Amphotericin B rarely
prevents death
 207

REVIEW QUESTIONS ?
1. A 12-year-old boy presents to the physician
due to recent neck pain. His mother is present
and states that soon after their recent family
vacation he began acting strange. Today his
temperature is 38.9°C (102.1°F). The physician
appreciates decreased range of motion of the
cervical spine. A lumbar puncture is performed
and reveals several amoebas. Which of the
following is most likely true of the patient’s
condition?
A. The patient was swimming in the ocean
during the vacation
B. The infectious organism is caused by a
trematode
C. Cysts will not be found in the cerebrospinal
fluid
D. Early administration of amphotericin B will
likely prevent death

• Correct answer: C
• The patient likely has Naegleria-related
meningoencephalitis based on the
following:
• Pain and decreased range of motion
in the neck
• Strange behavior
• Amoebas present in CSF
• Naegleria fowleri exists only in the
amoeba form and would not produce
cysts
• Choice A is incorrect because Naegleria
fowleri exists in freshwater only, not
saltwater as found in the ocean
• Choice B is incorrect because Naegleria
fowleri is a protozoa, not a trematode
• Choice D is incorrect because amphotericin
B is unlikely to prevent death, although it
should still be administered
208
Section 6 - Trypanosoma brucei, gambiense, and rhodesiense
1. African theme: African trypanosomiasis
2. Road: Trypanosoma rhodesiense
3. Gambling guards: Trypanosoma gambiense
4. Bruce Lee: Trypanosoma brucei
5. Teeny flies: transmitted through tsetse flies
6. Painful wounds on victims: painful and red ulcers at
the site of bites
7. Heat lamp with varied assortment of gems:
antigenic variation causes relapsing fevers for
months
8. Bad guy holding head: causes headaches
9. Garbled radio sounds for slurred speech: causes
slurred speech
10. Net with knots: causes enlarged lymph nodes
11. Comb on knocked out bad guy: leads to coma
12. Pit with bones: leads to death
13. Guards with hats: CNS penetration
14. Tripping goats: trypomastigotes
15. Goat head in pool of blood: diagnose by visualizing
trypomastigotes on peripheral blood smear
16. Syrup man: treat with suramin
17. Mellow yellow cans rolling: treat with melarsoprol
18. Protein drink: trypanosomes are protozoa
 209

REVIEW QUESTIONS
1. A 15-year-old boy presents to a humanitarian
Photo Credit: CDC/Dr. Myron G. Schultz [Public domain]
Figure 5.4.7 - Trypomastigotes on peripheral blood
smear
?
outreach clinic in South Africa. His mother is
speaking for him since the patient is poorly
responsive. The mother states that she saw
three red unexplained wounds on his arms
one week ago and did not think much of it at
the time. He has had a fever for three days
and recently complained of being really tired.
This morning he was barely arousable. On
physical exam, the patient is somnolent. The
three red wounds are ulcerated and presumed
to be bite marks. The physician is concerned
about a protozoan parasite penetrating the
patient’s central nervous system. The patient is
admitted to a nearby hospital and administered
melarsoprol. Which of the following is true
regarding the most likely causal organism?
A. Diagnosis is confirmed by the presence of
cysts on a blood smear
B. Fever cessation indicates resolution of the
disease
C. Mosquito eradication will not prevent
disease transmission
D. The red wounds indicative of bite mark
were likely painless

• Correct answer: C
• The patient likely has African sleeping
sickness (African trypanosomiasis)
based on the following:
• Lives in Africa
• Wounds consistent with “bug” bites
• Somnolence
• Treatment with melarsoprol
• African trypanosomiasis is transmitted
by Tsetse flies, not mosquitoes
• Choice A is incorrect because a blood smear
would reveal trypomastigotes
• Choice B is incorrect because fevers can
return due to high degree of antigenic
variation of the parasite
• Choice D is incorrect because tsetse fly bites
cause painful ulcers
210
Section 7 - Malaria
1. Mole area: Malaria (infection from Plasmodium
spp.)
2. Protein shakes: protozoa
3. Five pointed star on AXE can: Plasmodium vivax
4. Oval opening on sleeveless shirt: Plasmodium ovale
5. Clorox cleaner: treat P. vivax and ovale with
chloroquine
6. Hypnotist with Dalmation: P. vivax and ovale have
dormant hypnozoites in the liver
7. Clorox cleaner knocked down by Dalmation:
chloroquine cannot eliminate the liver hypnozoites
of P. vivax and P. ovale
8. Prom queen: treat hypnozoites with primaquine
9. Sweaty guy: malaria can cause sweating
10. Heat lamps: malaria can cause fever
11. Shaking weight lifter: malaria can cause shaking
chills
12. Spleen shaped welt: malaria can cause
splenomegaly
13. Popped red balloon: malaria can cause anemia
14. False pair: Plasmodium falciparum
15. 1 out of 3 red balloons popped: P. falciparum infects
1/3 of the patients red blood cells
16. Clogged vent: red blood cells killed by P. falciparum
can clog small vessels
17. Spilled kidney beans: P. falciparum-related clogging
of vessels causes kidney damage
18. Damaged lung test machine: P. falciparum-related
clogging of vessels causes lung damage.
19. Startled man on EEG: P. falciparum-related clogging
of vessels can damage the brain resulting in seizures
and coma
20. Pregnant woman spills sugar: P. falciparum can
cause severe hypoglycemia in pregnant women
21. Clorox cleaner helping out: treat P. falciparum
infections with chloroquine
22. Helpful artists: treat serious P. falciparum infections
with artemisinins
23. Queen with a “9” on her crown: treat serious P.
falciparum infections with quinine (quinidine)
24. Clorox cleaners all over scene: chloroquine
monotherapy is the treatment of choice unless the
patient has a serious P. falciparum infection, a P.
vivax/ovale infection, or has a chloroquine-resistant
strain
25. Attacking Iguanas and spilled ice cream: administer
proguanil and atovaquone for chloroquine-resistant
strains
26. Meatloaf stand: mefloquine may be administered
for chloroquine-resistant strains
27. Mosquitoes: malaria is transmitted by Anopheles
mosquitoes
28. Knocked over trough with red Gatorade: diagnose
by visualizing ring-form trophozoites within red
blood cells
 211

29. Two dogs: red blood cells infected by P. vivax/ovale
spp. burst every 2 days (48 hours)
30. “3”-shaped couch in fancy ‘Mole Ariae”: red blood
cells infected by P. malariae species burst every 3
days (72 hours)
31. Irregular and explosive behavior: red blood
cells infected by P. falciparum have an irregular
unpredictable bursting pattern

Figure 5.4.8 - Malaria Life Cycle

212

I. Red blood cells will burst and release merozoites

into the bloodstream → immunologic response
(fever and chills)
A. Different species burst at certain intervals
1. P. vivax/ovale burst every 48 hours
2. P. malariae burst every 72 hours
3. P. falciparum burst irregularly

Photo Credit: MichaelZahniser via Wikimedia Commons [Public domain]

Figure 5.4.9 - Plasmodium trophozoite ring form
within red blood cells

REVIEW QUESTIONS
1. An 18-year-old otherwise healthy male
complains of recurring episodes of chills and
excessive sweating. Since his return to the
United States from Papua New Guinea, he
describes reliably experiencing a fever, chills and
diaphoresis every 48 hours. On physical exam,
his abdomen is soft with mild organomegaly
in the left upper quadrant. A peripheral blood
smear is ordered.
Photo Credit: CDC [Public domain]
Chloroquine is administered. Based on the
most likely Plasmodium species, which of
the following is most likely to occur following
treatment?
A. Eradication of all exo-erythrocytic
Plasmodium forms
B. Multiple bouts of severe hypoglycemia prior
to recovery
C. Resolution followed by return of symptoms
months later
D. Worsening fever and chills for several
months
213
?
• Correct answer: C
• The patient most likely has an infection
with Plasmodium vivax or Plasmodium
ovale based on the following:
• Fever, chills, and diaphoresis in 48
hour intervals
• Blood smear revealing trophozoite
ring form
• Splenomegaly
• Chloroquine will eradicate the
erythrocytic parasites, not the liver
hypnozoites in the exo-erythrocytic
forms. When the dormant hypnozoites
become active in the bloodstream,
symptoms will return
• Choice A is incorrect because chloroquine
will not eradicate the exo-erythrocytic life
forms
• Choice B is incorrect because severe
hypoglycemia occurs in pregnant individuals
• Choice D is incorrect because chloroquine
will not worsen these symptoms
214
Section 8 - Babesia
1. Babies: Babesia
2. Tick toy and Tic Tacs: transmitted through ticks
3. Dust spores: tick saliva carries sporozoites
4. Map of NE United States: ticks with Babesia live in
the NE United States
5. Spores blasting baby into trough: sporozoites
become trophozoites in red blood cells
6. Spilled red paint: causes anemia
7. Baby finger painting on wall: diagnosed on
peripheral blood smear
8. Gold cross: blood smear reveals “Maltese cross”
(intraerythrocytic ring form)
9. Baby dangling on chains: dianose with polymerase
chain reaction (PCR)
10. Protein drink: Babesia is protozoan
11. Sleeping baby: can cause fatigue
12. Heat lamps: can cause fever and flu-like symptoms
13. Cleaning lady: can be treated with clindamycin
14. Queen’s Crown with number nine: can be treated
with quinine
15. Cleaning lady with crown: administer clindamycin
and quinine together
16. Toe with an ice cream cone on it: can treat with
atovaquone
17. Zip line: can treat with azithromycin
18. Zip line baby and Ice cream baby: administer
atovaquone and azithromycin
19. Spleen shaped spot: the spleen is important in
clearing infection (worse outcome in asplenic
patients)
 215

REVIEW QUESTIONS
1. A 34-year-old asplenic patient presents to
Photo Credit: Riccardoariotti [CC BY 3.0 (https://creativecommons.org/
licenses/by/3.0)]
Figure 5.4.10 - Babesia trophozoite ring form
(“Maltese cross”) within red blood cells
?
the physician due to malaise, progressive
fatigue, and shortness of breath. He endorses
recent hiking through a forested area in
Massachuchets. His temperature is 39.0°C
(102.2°F). The physician suspects an infection
spread through an arachnid endemic to the
region. After thorough skin inspection, the
physician finds an Ixodes tick on the patient’s
back. Which of the following is most likely true
regarding the patient’s illness?
A. Trophozoites were transmitted from the
tick’s saliva into the blood
B. A complete blood count would reveal a
normal hematocrit level
C. Erythromycin should be considered as part
of the treatment
D. Peripheral blood smear would reveal
intraerythrocytic ring forms

• Correct answer: D
• The patient likely has Babesia based on
the following:
• Tick bite
• Malaise and fever
• Symptoms of anemia (shortness of
breath and fatigue)
• Asplenic
• Intraerythrocytic ring forms (“Maltese
cross”) would be visualized on
peripheral blood smear
• Choice A is incorrect because ticks transmit
sporozoites
• Choice B is incorrect because the patient is
likely anemic
• Choice C is incorrect because azithromycin,
not erythromycin, can treat Babesia
216
Section 9 - Trypanosoma cruzi
1. Cruise line: Trypanosoma cruzi
2. Red bugs: transmission via reduviid bugs
3. Couple kissing: reduviid bugs are also known as
“kissing” bugs
4. Man in protective clothing: prevent bites using long-
sleeved clothing
5. Insect repellent: prevent bites using insect repellent
6. Tripping goats: diagnose with trypomastigotes on
peripheral blood smear
7. Poop in red paint: reduviid bugs leave feces in bite
wounds
8. Man in hat covered with paint: infection can cause
meningoencephalitis
9. Heat lamps: can cause fever
10. Goat trapped in net: can cause lymphadenopathy
11. Sick girl: can cause malaise and flu-like symptoms
12. Chugging contest: causes Chagas disease
13. Protein drink: protozoa
14. Weighed down car with popped tire: Chagas disease
causes dilated cardiomyopathy
15. Vent on car: Chagas disease causes ventricular
tachycardia
16. Brown cookie tube: Chagas causes megacolon
17. Giant frosting dispenser: Chagas disease causes
achalasia
18. Knife, fur, and ox head: treat with nifurtimox
19. Bean knitting: treat with benznidazole
Photo Credit: Farnoosh Farrokhi, Michael F. Vaezi. [CC BY 2.0 (https://
creativecommons.org/licenses/by/2.0)]
Figure 5.4.11 - Barium esophagram showing
achalasia

REVIEW QUESTIONS
1. A 14-year-old girl presents to the clinic with
a fever after returning from a trip to South
America. Although she remembers getting
bitten by some bugs during her visit, she
did not think much of them because the
bites were painless. Other members of her
family in the United States have not felt sick.
Physical examination reveals a nontender
and nondistended abdomen. A peripheral
blood smear is ordered and trypomastigotes
are visualized as shown below. Which of the
following is true regarding the acute stage of
her infection?
Photo Credit: Deautsch: PD-DPD Image Library [Public domain]
A. Swallowing may become difficult
B. Nifurtimox may prevent meningeal
inflammation
C. Treat members of her household to prevent
transmission
D. Lymphadenopathy is unlikely
E. Melarsoprol may prevent somnolence and
coma
217
?
• Correct answer: B
• The patient likely has acute Chagas
disease based on the following:
• Fever
• Painless bites
• Travel to South America
• Trypomastigotes on blood smear
• Patients should be given nifurtimox or
benznidazole during the acute phase
which may prevent meningitis or
lymphadenopathy
• Choice A is incorrect because achalasia is
caused by chronic Chagas disease
• Choice C is incorrect because Trypanosoma
cruzi is only transmitted by the reduviid bug
• Choice D is incorrect because
lymphadenopathy is possible during the
acute phase
• Choice E is incorrect because melarsoprol
treats African trypanosomiasis, not Chagas
disease
218
Section 10 - Leishmania donovani
1. Leashed maniac: Leishmania donovani
2. Sand person flying through the air: transmitted
through sandfly bites
3. Man being bitten by sand person: bites cause
painful ulcers
4. Skin wounds: cutaneous leishmaniasis
5. People impaled through viscera: visceral
leishmaniasis
6. Spikes and heat lamps: causes spiking fevers
7. Ballooning spleens: causes splenomegaly
8. Liver-shaped spot on bloating dog: causes
hepatomegaly
9. Assorted deflated balloons on frying pan: causes
pancytopenia
10. Skeleton: severe pancytopenia among patients with
visceral leishmaniasis has a mortality rate of 90%
11. Protein drink: protozoa
12. Masked goat traipsing through blood: amastigotes
seen on peripheral blood smear
13. Glue causing stye in the eye: treat with
stibogluconate
14. Amphibians: treat with amphotericin B
 219

REVIEW QUESTIONS ?
1. A 23-year-old male presents with a red sore on
his left calf that he first noticed 3 days ago. Last
week, he returned from a trip to Ethiopia and
recalls being bitten by a fly during his stay. He
denies fevers or abdominal pain. An abdominal
exam reveals no palpable organomegaly. The
physician orders a peripheral blood smear which
Photo Credit: Abanima at the Arabic language Wikipedia [CC BY-SA 3.0 reports the presence of multiple amastigotes
(http://creativecommons.org/licenses/by-sa/3.0/)]
found in macrophages. Based on these findings,
Figure 5.4.12 - Cutaneous leishmaniasis
which of the following insects most likely bit the
patient?
A. Sandfly
B. Deer fly
C. Mango fly
D. Tsetse fly

• Correct answer: A
• The patient likely has cutaneous
leishmaniasis based on the following:
• Red sore
• Fly bite
• Trip to Ethiopia
• Amastigotes on blood smear
• Leishmania donovani is transmitted by
the sandfly
• Choice B and C are incorrect because these
transmit Loa Loa
• Choice D is incorrect because the tsetse fly
transmits Trypanosoma brucei, gambiense,
and rhodesiense
220

Section 11 - Trichomonas vaginalis

1. Moaning tricycle boy: Trichomonas vaginalis
2. Barrel of alkaline bleach: the pH of the vaginal
discharge pH > 4.5
3. Trough: has motile trophozoites
4. Strawberries: causes cervicitis resulting in a
“strawberry red” cervix
5. Protein drink: protozoa
6. Spilled frothy alcohol: yellow, frothy vaginal
discharge
7. Microscope in fluid: diagnosed on saline microscopy
8. Couple on Metro: treat both partners with
metronidazole
9. Scarlet letter: is a sexually transmitted infection
 221

REVIEW QUESTIONS
1. A 30-year-old woman reports abnormal vaginal
Photo Credit: isis325 via Flickr
Figure 5.4.13 - Flagellated Gardnerella trophozoites
?
discharge for the past 5 days. She states that
the discharge is foamy and greenish-yellow in
color. After obtaining a more detailed history,
she states that she recently became sexually
active with a new partner. The physician
performs a speculum exam and appreciates an
erythematous cervix. A sample of the vaginal
discharge is then obtained and promptly
examined under the microscope. Microscopy
reveals several protozoan organisms with
noticeable flagella. Based on the information
provided, which of the following statements is
most likely true?
A. She obtained the infection from her partner
B. A pH of 3.7 would rule out T. vaginalis
C. The pathogen is part of the normal vaginal
flora
D. Clue cells will indicate the likely cause of her
infection

• Correct answer: A
• Trichomonas vaginalis is the most likely
organism based on the following:
• Foamy, greenish-yellow discharge
• Erythematous cervix
Photo Credit: CDC [Public domain] • New sexual partner
Figure 5.4.14 - Gardnerella vaginalis on saline • Flagellated protozoa on saline
microscopy microscopy
• Trichomonas vaginalis is sexually
transmitted
• Choice B is incorrect because evidence of
flagellated protozoa makes Trichomonas
vaginalis most likely, regardless of an
inconsistent vaginal pH
• Choice C is incorrect because Trichomonas
vaginalis is not part of the normal vaginal
flora
• Choice D is incorrect because clue cells
occur with Gardnerella vaginalis infections
222

Section 12 - Enterobius vermicularis (pinworm)

1. Pinball machine: pinworm 6. Tape removed by child: diagnosed by viewing eggs

2. Vermin: Enterobius vermicularis (pinworm) under the microscope following a tape test
3. Merry-go-round: roundworm (nematode) 7. Pyro kid with Pam spray: treat with pyrantel
4. Wedgie: causes anal pruritus pamoate
5. Poop on face: fecal-oral transmission 8. Bent phone: treat with bendazoles
 223

REVIEW QUESTIONS ?
1. A 5-year-old boy is brought to the physician
by his concerned mother who states that he
is constantly scratching his butt. The mother
first noticed this habit several weeks ago after
her son began attending kindergarten. Physical
examination reveals erythema surrounding the
perianal region. An adhesive tape is placed in
the perianal region and transferred to a glass
slide. The slide is viewed under light microscopy
and reveals the presence of eggs. This patient’s
Photo Credit: CDC [Public domain] condition is best treated with which of the
Figure 5.4.15 - Pinworm egg following medications?
A. Ivermectin
B. Diethylcarbamazine
C. Pyrantel pamoate
D. Praziquantel
E. Doxycycline

• Correct answer: C
• This patient has a pinworm infection
• The boy has been constantly scratching
his butt
• An adhesive tape placed in the perianal
region revealed the presence of eggs
when viewed under light microscopy
• The treatment for this parasitic infection
is pyrantel pamoate (can also be treated
with mebendazole)
• The other answer choices (A, B, D, and E)
are antiparasitic medications but none of
them are used to treat pinworm
224

Section 13 - Ascaris lumbricoides (giant roundworm)

1. Asterisks: Ascaris lumbricoides (giant roundworm)
2. Giant man: Ascaris lumbricoides (giant roundworm)
3. Merry-go-round: roundworm (nematode)
4. Man stepping in poop: fecal-oral transmission
5. Spit and Loafer shoes: causes Löffler syndrome
6. Man working on valve of pipe: may cause
obstruction at the ileocecal valve
7. Perforated hose: causes intestinal perforation
8. Man sprayed in the mouth: migrates to the
mouth and nose before descending back into the
gastrointestinal tract
9. Banana trees: may cause biliary obstruction
10. Colored rocks: diagnosed by detecting knobby-
coated oval eggs in the feces via microscopy
11. Bent phone: treat with bendazoles

Figure 5.4.16 - Life cycle of parasites that cause Löffler syndrome


Photo Credit: CDC [Public domain]
Figure 5.4.17 - Ascaris lumbricoides egg
REVIEW QUESTIONS
1. A 6-year-old boy is brought to the physician
by his mother because of a 1-month history of
intermittent right upper quadrant abdominal
pain. Upon further inquiry she states that a
month or so ago he developed a cough which
has since resolved. Physical examination reveals
mild discomfort in the right upper quadrant of
the abdomen. A stool culture is shown below.
This patient is at risk of developing which of the
following?
Photo Credit: CDC/ Dr. Mae Melvin [Public domain]
A. Myocarditis
B. Appendicitis
C. Visual impairment
D. Seizures
225
?
• Correct answer: B
• This patient has an Ascaris lumbricoides
infection
• 1-month history of intermittent RUQ
pain → biliary problems
• A cough a month or so ago → Löffler
syndrome
• Stool culture shows a parasitic
egg  (seen in the image)
• Ascaris lumbricoides may cause
obstruction at the ileocecal valve which
is in close proximity to the appendix →
appendicitis
• A is incorrect because this is suggestive of
Toxocara canis which does not cause Löffler
syndrome and isn’t typically associated with
biliary colic
• C is incorrect because this is suggestive
of Toxocara canis, Onchocerca volvulus,
and Loa loa but these aren’t associated
with biliary colic and do not cause Löffler
syndrome
• D is incorrect because seizures are
suggestive of Toxocara canis or Taenia
solium, but these do not causes biliary colic
or Löffler syndrome
226
Section 14 - Strongyloides stercoralis (threadworm)
1. Strong contestants: Strongyloides stercoralis
(threadworm)
2. Threads on sports bra: Strongyloides stercoralis
(threadworm)
3. Merry-go-round: roundworm (nematode)
4. Rabbi: diagnosed with microscopy (rhabditiform
larvae in the feces)
5. Confetti popper: autoinfection
6. Confetti on skin: initiates the infection via
penetration of the skin
7. Confetti over hose and pool: can penetrate the
intestinal wall and enter the bloodstream
8. Loafer shoes: causes Löffler syndrome
9. Bent phone: treat with bendazoles
10. Ivory tusk: treat with ivermectin

Photo Credit: CDC [Public domain]
Figure 5.4.18 - Strongyloides stercoralis larva
REVIEW QUESTIONS
1. A 31-year-old female presents to the physician
due to a chronic cough. She states that she first
noticed the cough approximately one year ago
after traveling to Thailand. Physical examination
reveals a high pitched sound over both lung
fields best heard during expiration. A complete
blood cell count reveals elevated levels of
eosinophils but is otherwise normal. Stool
examination reveals an absence of parasitic
eggs. This patient’s condition can be best
characterized by which of the following?
A. Disruption of granuloma formation
B. Hyperplasia and hypertrophy of respiratory
goblet cells
C. Penetration of the alveoli by a parasite
D. Noncaseating granulomas
• Correct answer: C
• This patient has a Strongyloides stercoralis
infection resulting in Löffler syndrome
• Developed a cough one year ago after
traveling to Thailand
• Wheezing (high pitched sound over
both lung fields)
• Eosinophilia
• Strongyloides penetrates the skin,
enters the bloodstream, and then
penetrates the alveoli causing
pulmonary symptoms
• The organism ascends the trachea and
descends into the GI tract where the
mature parasite remains
227
?
• Strongyloides is unique because the
eggs released from the mature helminth
hatch within the intestines
• Within the intestines they can penetrate
the gastrointestinal wall and migrate
into the bloodstream causing the cycle
to repeat itself
• The unique life cycle of Strongyloides
means it can cause repeated bouts of
Löffler syndrome (eg, chronic cough)
• The eggs hatch inside of the host
intestines so eggs will not be detected
in the stool (only larvae will be)
• A is a reference to secondary TB but this
typically presents with weight loss, fevers,
night sweats, and hemoptysis so this is
unlikely
• B is a reference to pathological findings
of COPD which is not associated with
eosinophilia
• D is a reference to pathological findings
of sarcoidosis which can cause pulmonary
findings, but not typically associated with
eosinophilia
228
Section 15 - Ancylostoma duodenale and Necator americanus (hookworms)
1. Ancestry tree: Ancylostoma duodenale
2. Nectarine tree: Necator americanus
3. Fishing hook: hookworms
4. Merry-go-round: roundworm (nematode)
5. Man stepping on nectarine: transmitted via larvae
penetration of the skin
6. Deflated balloon: cause anemia by sucking blood
from the intestinal wall
7. Itchy snake tattoo: cause a pruritic maculopapular
rash (often described as serpiginous)
8. Loafer shoes: cause Löffler syndrome
9. Pyro kid with Pam spray: treat with pyrantel
pamoate
10. Bent phone: treat with bendazoles
 229

REVIEW QUESTIONS ?
1. A 14-year-old boy is brought to the physician
due to a persistent cough that began yesterday.
The family recently returned from a trip to the
beaches of Oregon where the patient walked
around barefoot. A complete blood cell count
reveals elevated levels of eosinophils but is
otherwise normal. The physician suspects
a parasitic infection and orders a stool
preparation but no organisms are seen. What
finding will most likely be observed in this
Photo Credit: CDC [Public domain] patient?
Figure 5.4.19 - Hookworm egg A. Conjunctival pallor
B. Diarrhea
C. A chest x-ray with round opacities seen on
both lung fields
D. Hookworm larvae in the gastrointestinal
tract

• Correct answer: C
• This patient has a hookworm infection
resulting in Löffler syndrome
• A cough after walking around barefoot
on the beaches of Oregon
• Eosinophilia
• The physician suspects a parasitic
Photo Credit: CDC [Public domain] infection
Figure 5.4.20 - Cutaneous hookworm lesion • Hookworms penetrate the skin, migrate
to the bloodstream, and then penetrate
the alveoli → Löffler syndrome → round
opacities seen on both lung fields
• The lifestyle of hookworms is unique
in that Löffler syndrome is a transient
acute condition (the parasite has not
yet descended into the gastrointestinal
tract → absence of GI symptoms and
negative stool sample)
• A, B, and D can be caused by hookworms,
but this patient’s cough only started
yesterday and his stool sample is negative
• The pathogen hasn’t yet descended into the
gastrointestinal tract so anemia, diarrhea,
and larvae in the gastrointestinal tract
would be unlikely
230
Section 16 - Trichinella spiralis
1. Tricycle on spiral-shaped pathway: Trichinella
spiralis
2. Merry-go-round: roundworm (nematode)
3. Peter’s Pork: transmitted through undercooked
meat (especially pork)
4. Customer stepping on poop: also exhibits fecal-oral
transmission
5. Bloody stream: disseminates into the bloodstream
6. Bricks: encysted larvae infect striated muscle tissue
7. Fire by bricks: causes muscle inflammation and
myalgias
8. Heat lamps: may cause fever
9. Toy minion: may cause periorbital edema
10. Vomiting boy: may cause nausea and vomiting
11. Bent phone: treat with bendazoles
 231

REVIEW QUESTIONS ?
1. A 23-year-old male presents to the physician
due to calf pain that he first noticed one week
ago. Yesterday the pain was so severe that
he was unable to walk. He denies any recent
change in activity. Physical examination is
significant for periorbital edema and muscle
tenderness over the posterior aspect of the
left leg. A muscle biopsy is obtained and shown
below. This patient most likely developed the
infection after:

Photo Credit: TheMrGrove [CC BY-SA 4.0 (https://creativecommons.org/

licenses/by-sa/4.0)]
Figure 5.4.21 - Striated muscle tissue infected with
Trichinella spiralis

Photo Credit: Froggerlaura at English Wikipedia [modified]

A. Consuming undercooked pork

B. Larvae penetration of the skin
C. Exposure to the ixodes deer tick
D. Surfing in a tropical area

• Correct answer: A
• This patient has a Trichinella spiralis
infection
• Calf pain, periorbital edema and a
muscle biopsy shows a spiral-shaped
organism within muscle tissue
• This organism is transmitted via
consumption of undercooked pork
• The organism infects the muscle tissue
where encysted larvae may be seen (as
shown in the image)
• B is describing Strongyloides stercoralis but
this infects the lungs and gastrointestinal
tract so myalgias and an organism seen on a
muscle biopsy would be unlikely
• C is referencing several organisms such
Photo Credit: Klaus D.Peter, Gummersbach, Germany [CC BY 3.0 de (https://
creativecommons.org/licenses/by/3.0/de/deed.en)] as Borrelia burgdorferi, Anaplasma, or
Figure 5.4.22 - Periorbital edema Ehrlichia, but these are not spiral shaped
organisms and do not directly infect muscle
tissue
• D is a reference to Leptospira interrogans
which is spiral shaped, but a muscle biopsy
would not reveal spiral shaped larvae within
muscle tissue
232

Section 17 - Trichuris trichiura (whipworm)

1. Whip: Trichuris trichiura (whipworm)
2. Merry-go-round: roundworm (nematode)
3. Poop splashed on mouth: fecal-oral transmission
4. Loose stool: may cause loose stools
5. Happy girl: often asymptomatic
6. Deflated red balloon: may cause anemia
7. Pouch on rear end: may cause rectal prolapse in
children
8. Bent phone: treat with bendazoles
 233

REVIEW QUESTIONS ?
1. A resident physician is in Honduras on a
humanitarian trip when an 8-year-old girl is
brought to the clinic due to several months
of fatigue. Physical examination reveals
conjunctival pallor. Laboratory analysis of the
stool reveals the presence of eggs belonging
to a roundworm. After thorough evaluation
the resident physician explains that without
treatment, the patient is at risk of developing
rectal prolapse in the setting of a heavy
Photo Credit: Unknown photographer/CDC [Public domain] infection. This patient’s condition is best treated
Figure 5.4.23 - Whipworm egg with which of the following?
A. Watchful waiting
B. Mebendazole
C. Ivermectin
D. Diethylcarbamazine

• Correct answer: B
• This girl has an infection caused by Trichuris
trichiura
• Anemia (fatigue and conjunctival pallor)
• Laboratory analysis has confirmed that
the anemia is due to a roundworm
• The resident concludes that this
infection increases the risk of
developing rectal prolapse
• Trichuris trichiura should be treated
with mebendazole
• A is wrong because without treatment this
patient is at risk of developing ongoing
anemia, diarrhea, and rectal prolapse
• C is wrong because while this may have
some efficacy against whipworm, it has not
been shown to be as effective as bendazoles
• D is wrong because diethylcarbamazine
is used to treat Loa loa and Wuchereria
bancrofti
234

Section 18 - Toxocara canis

1. Toxic cloud over cans: Toxocara canis
2. Round gears: roundworm (nematode)
3. Brown mess: fecal-oral transmission
4. Brown juice through sieve turns red: larvae migrate
through the intestinal wall into the bloodstream
5. Dalmatian dog: transmitted through dog feces
6. Liver shaped spot: affects the liver
7. Juice on sunglasses: affects the eyes resulting in
visual impairment and blindness
8. Muscular guy in car: myocarditis
9. Sleeping man with hat: CNS penetration resulting in
coma
10. Alarm Clock: CNS penetration resulting in seizures
11. Bent phone: treat with bendazoles
 235

REVIEW QUESTIONS ?
1. A 4-year-old boy is brought to the physician
by his mother due to recent changes in his
skin color. She states that several weeks
ago they started going to a new playground
contaminated with dog feces, and is worried
her son may have become ill after accidental
ingestion of the feces. His temperature is 38.7°C
(101.6°F). Physical examination reveals jaundice
of the skin and hepatomegaly. Laboratory
analysis of the patient’s blood is significant for
transaminitis and elevated levels of eosinophils.
An enzyme-linked immunosorbent assay test
detects IgG antibodies to antigens secreted by a
roundworm. This patient’s condition:
A. Is transmitted through larvae penetration of
the skin
B. Should be treated with ivermectin
C. Can be best explained by autoinfection
D. May cause myocarditis

• Correct answer: D
• This boy has hepatitis caused by Toxocara
canis
• He likely ingested dog feces (risk factor
for Toxocara)
• He has a fever (38.7°C), jaundice, and
hepatomegaly → hepatitis
• An ELISA test detected the presence of a
roundworm
• Toxocara canis also causes myocarditis
• A , B, and C, are all suggestive of
Strongyloides stercoralis which is
transmitted when larvae penetrate the skin
236

Section 19 - Onchocerca volvulus

1. Crowd yelling “encore”: Onchocerca volvulus 6. Girl sneezing: microfilariae may cause an allergic
2. Merry-go-round: roundworm (nematode) reaction
3. Fly suit: transmitted through the female blackfly 7. Sunglasses by the river: may cause river blindness
4. Bumps on the bouncer: causes subcutaneous 8. Ivory tusks: treat with ivermectin
nodules
5. Loose string: loss of elastic fibers resulting in skin
atrophy
 237

REVIEW QUESTIONS ?
1. A resident physician is in Kenya on a
humanitarian trip when a 37-year-old male is
brought to the clinic due to blurry vision which
began several months ago. The patient also
states that he has had small hard bumps on his
skin which he noticed several years ago. Physical
examination reveals subcutaneous nodules
prevalent over the pelvic girdle. Slit-lamp
examination reveals microfilariae in the anterior
chamber of the eye. After thorough evaluation,
the resident informs the team that this patient’s
condition was likely transmitted through the
female blackfly. This patient’s condition is best
Photo Credit: John Curtis’s British Entomology 1824–1840 [Public domain]
treated with which of the following?
Figure 5.4.24 - Blackfly
A. Praziquantel
B. Mebendazole
C. Ivermectin
D. Diethylcarbamazine

• Correct answer: C
• This patient has an infection caused by
Onchocerca volvulus
• Blurry vision, subcutaneous nodules,
and a slit-lamp exam has revealed
microfilariae in the eye
• Transmitted by the female blackfly
• Loa loa can present similarly but is not
transmitted by the female blackfly
• A and B are wrong because these are not
first-line treatments for either Onchocerca
volvulus or Loa loa
• D is wrong because this is used to treat Loa
loa but not Onchocerca volvulus
238
Section 20 - Loa loa and Wuchereria bancrofti
1. Lara Croft: Wuchereria bancrofti
2. Luau: Loa loa
3. Merry-go-round tattoo: roundworms (nematodes)
4. Horse, deer, and mango: Loa loa is transmitted by
the deer fly, horse fly, and mango fly
5. Swollen worms: Loa loa causes swelling of the skin
6. Tribe member inspecting worms: Loa loa may
migrate to the conjunctiva resulting in transient
ocular edema and inflammation
7. Mosquitoes: Wuchereria bancrofti is transmitted by
female mosquitoes
8. Elephant: Wuchereria bancrofti causes lymphatic
filariasis (elephantiasis)
9. Beaded net: Wuchereria bancrofti invades the
lymphatic system resulting in inflammation and
lymphedema
10. One arrow in quiver: symptoms begin approximately
9 months to 1 year following infection
11. Pistol with magazines of ammo: Loa loa
and Wuchereria bancrofti are treated with
diethylcarbamazine

REVIEW QUESTIONS
1. A resident physician is in Uganda on a
Photo Credit: Courtesy of the US Department of Health and Human Services
Figure 5.4.25 - Elephantiasis
239
?
humanitarian trip when a 47-year-old male
is brought to the clinic due to eye pain which
began several days ago. The patient also states
that he has experienced several episodes of
pain and pruritus on the face over the past
several weeks. Physical examination reveals
subcutaneous edema prevalent over the cheeks.
Slit-lamp examination reveals conjunctivitis.
After thorough evaluation, the resident informs
the team that this patient’s condition was likely
transmitted by a:
A. Female mosquito
B. Tsetse fly
C. Deer fly
D. Sandfly
• Correct answer: C
• This patient has an infection caused by Loa
loa
• Conjunctivitis and subcutaneous edema
in the face are unique to this parasite
• Loa loa is transmitted by the deer fly,
horse fly, and mango fly
• A  is a reference to Wuchereria bancrofti,
but this causes elephantiasis
• B is a reference to Trypanosoma brucei, but
this causes somnolence and coma
• D is a reference to Leishmania donovani,
but this causes spiking fevers, skin ulcers,
hepatomegaly, and pancytopenia
240
Section 21 - Taenia solium
1. Tanning salon: Taenia solium
2. Eating pig meat with cysts: transmission of encysted
larvae in undercooked pork
3. Taped worm: tapeworm
4. Worms in mud: ingestion of encysted larvae leads to
intestinal tapeworm (diarrhea)
5. Pretzel: treat intestinal tapeworm with praziquantel
6. Health inspector examining egg from mud: diagnose
intestinal tapeworm by identifying eggs in stool
7. Eggs in poo: ingestion of eggs from human feces
8. Woman with boils: ingestion of eggs causes
cysticercosis
9. Boil on head: cysticerci in the brain causes
neurocysticercosis
10. Stepped on hose: neurocysticercosis can cause
obstructive hydrocephalus
11. Malfunctioning tanning bed: neurocysticercosis can
cause seizures
12. Beam of light on woman’s head: diagnose
neurocysticercosis with a CT scan
13. Receptionist eating pretzel: treat cysticercosis with
praziquantel
14. Harvey Porter and Albus: treat neurocysticercosis
with albendazole
 241

Figure 5.4.26 - Taenia solium life cycle

Photo Credit: Pjgalindo [CC BY-SA 3.0 (https://creativecommons.org/licenses/

by-sa/3.0/)]
Figure 5.4.27 - Taenia solium on microscopy

Photo Credit: CDC [Public domain]

Figure 5.4.28 - Taenia solium egg in stool sample
242

REVIEW QUESTIONS ?
1. A 45-year-old butcher presents to the clinic
with diarrhea and abdominal pain for several
weeks. He indicates that he routinely eats
scraps of uncooked pork while he is butchering.
The physician notes that the patient may have
acquired a tapeworm infection from the pork.
Assuming the physician is correct, which of the
following statements is true?
A. The infection may eventually cause seizures
B. Diagnosis will be confirmed with eggs found
in the stool
C. Albendazole should be part of the
treatment regimen
D. The patient ingested T solium eggs to
acquire the infection

• Correct answer: B
• The patient likely has intestinal
Photo Credit: Rjgalindo [CC BY-SA 3.0 (https://creativecommons.org/licenses/
tapeworm based on the following:
by-sa/3.0/)] • Diarrhea and abdominal pain
Figure 5.4.29 - Neurocysticercosis on imaging • Regular ingestion of undercooked
pork
• Intestinal tapeworm is diagnosed by
identifying eggs in stool
• Choice A is incorrect seizures occur in
neurocysticercosis which is acquired by
eating Taenia eggs in feces
• Choice C is incorrect because albendazole is
used to treat neurocysticercosis
• Choice D is incorrect because intestinal
tapeworm is acquired through ingestion of
cysts in undercooked pork

Section 22 - Diphyllobothrium latum
1. “Dive For A Bath” sign: Diphyllobothrium latum
2. Taped worms: tapeworm
3. Kobe Bryant low in the pit: infection causes B12
deficiency
REVIEW QUESTIONS
1. An 8-year-old girl presents to the physician
due to a 2-month history of worsening fatigue.
Physical examination reveals conjunctival pallor.
Blood tests are performed which reveal a
hemoglobin of 9.4 g/dL and a mean corpuscular
volume of 108 fL. After thorough evaluation the
physician prescribes praziquantel. Based on the
causal organism, which of the following is a true
statement?
A. Transmission occurred through uncooked
pork
B. Cobalamin levels are likely elevated
C. Anaphylaxis may result from cyst rupture
D. Transmission occurred through the
ingestion of larvae
243
4. Moon: B12 deficiency causes megaloblastic anemia
5. Dead fish: transmitted through ingestion of
undercooked fish
6. Pretzel: praziquantel
?
• Correct answer: D
• The patient likely has Diphyllobothrium
latum based on the following:
• Macrocytic anemia (high MCV and
low Hb)
• Symptoms of anemia (fatigue and
conjunctival pallor)
• Treatment with an antiparasitic
(praziquantel)
• Diphyllobothrium latum is transmitted
through ingestion of larvae in
undercooked fish
• Choice A is incorrect because undercooked
pork transmits other parasites (eg, taenia
solium)
• Choice B is incorrect because
Diphyllobothrium latum causes low B12
(cobalamin)
• Choice C is incorrect because anaphylaxis
occurs with Echinococcus cyst rupture
244
Section 23 - Echinococcus granulosus
1. Crazy cock lady: Echinococcus granulosus
2. Worms taped to table: tapeworm
3. Chicken eggs in dog poop: transmission via egg-
infested dog feces
4. Sheep in dog food bowl: sheep are intermediate
hosts
5. Baby chick in poop track shaped like intestines: eggs
hatch into larvae within the intestines
6. Bulging tears in bean bag: hydatid cysts form in the
liver
Figure 5.4.30 - Echinococcus granulosus life cycle
7. Big bean bag: hydatid cysts cause hepatomegaly
8. Bean bag contents landing on girl: cyst rupture can
cause anaphylaxis
9. Harvey Porter and Albus: treat with albendazole
10. Alcohol bottle: inject cyst with alcohol prior to
surgery
11. Scalpel in first aid box: surgically remove the hydatid
cyst
 245

REVIEW QUESTIONS ?
1. A 45-year-old female presents to the physician
with right upper quadrant pain. Physical
examination reveals hepatomegaly. A CT
scan is performed which reveals a liver mass
surrounded by a white ring of calcification. The
mass is not consistent with an abscess. Plans are
made to surgically remove the mass following
an albendazole regimen. How did the patient
most likely acquire the infection causing the
mass?
Photo Credit: Ganimedes [CC BY-SA 4.0 (https://creativecommons.org/ A. Larvae in dog feces
licenses/by-sa/4.0)] from Wikimedia Commons
B. Eggs in dog feces
Figure 5.4.31 - Echinococcus granulosus tapeworm C. Larvae in sheep feces
on microscopy D. Eggs in sheep feces

• Correct answer: B
• The patient most likely has hydatid cysts
from Echinococcus granulosus based on
the following:
• RUQ pain
• Hepatomegaly
• CT scan revealing “eggshell
calcification”
• Pre-surgical albendazole regimen
• Echinococcus granulosus is acquired
through ingestion of eggs found in dog
feces
• Choice A is incorrect because eggs hatch
into larvae in the intestines after ingestion
Photo Credit: Wenya Liu, Eric Delabrousse, Oleg Blagosklonov, Jing Wang, • Choices C and D are incorrect because
Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton
and Hao Wen [CC BY 4.0 (https://creativecommons.org/licenses/by/4.0)], via
humans do not acquire infection through
Wikimedia Commons, adjustments made sheep feces
Figure 5.4.32 - Liver hydatid cyst on MRI

Photo Credit: By Yale Rosen via Flickr, adjustments made

Figure 5.4.33 - Liver hydatid cyst (gross)
246
Section 24 - Schistosoma haematobium, mansoni, and japanicom
1. Twin sisters: Schistosoma
2. Tree of toads: trematodes
3. Eggs with spines on side: eggs of S. mansoni and
japanicom have lateral spines
4. Smashed eggs: eggs of S. haematobium have
terminal spines
5. Eggs: Schistosoma eggs have spines
6. Hatching eggs: eggs only hatch in freshwater
7. Larvae from eggs: eggs release immature larvae
8. Glowing snail: immature larvae must infect
freshwater snail (intermediate host)
9. Glowing toxic circles: snails release mature larvae
called cercariae
10. Woman swimming in pond: cercariae infect humans
through skin (e.g. open wounds)
11. Laser pointing to crotch: can cause hematuria
12. Hematuria sounds like haematobium: Schistosoma
haematobium
13. Hope ribbon: chronic bladder infection can cause
squamous cell carcinoma of the bladder
14. Japanese embassy: S. mansoni and japanicom
15. Spleen shaped welt: S. mansoni and japanicom can
cause splenomegaly
16. Muddy water: S. mansoni and japanicom can cause
diarrhea
17. Ulcer shaped chunk of dirt: S. mansoni and
japanicom can cause intestinal ulceration leading to
iron deficiency anemia
18. Shattered port-hole: S. mansoni and japanicom can
cause portal hypertension
19. Fat dalmatian dog falling from boat: S. mansoni and
japanicom can cause hepatomegaly
20. Gnarled fibrous branches: S. mansoni and
japanicom can cause liver cirrhosis
21. Steam from pressure cooker: all species can cause
pulmonary hypertension
22. Pretzels: treat all forms of schistosomiasis with
praziquantel
 247

REVIEW QUESTIONS ?
1. A 65-year-old Middle-eastern female presents
to the clinician due to worsening fatigue and
dark red diarrhea that began 5 years ago. She
emigrated to the United States 1 year ago.
Physical examination reveals a palpable spleen
and liver enlargement. A stool sample was sent
to the pathologist and the results are shown
below.

Figure 5.4.34 - Schistosoma life cycle

Photo Credit: CDC [Public domain]

2. Which of the following is true regarding this

pathogen?
A. It infects the vasculature of the bladder
B. Eggs must hatch in saltwater
C. It can infiltrate lung alveoli causing cough
D. It can cause a decreased MCV and Hb

• Correct answer: D
• The patient likely has an infection with
S. mansoni or S. japanicom based on the
Photo Credit: Wikimedia Commons [Public domain]
following:
Figure 5.4.35 - Lateral spine on Schistosoma egg
• Parasitic egg with a lateral spine
(mansoni or japanicom)
• Hepatosplenomegaly
• Bloody diarrhea
• Fatigue (symptom of anemia)
• Schistosoma mansoni or japanicom can
ulcerate the intestines causing chronic
blood loss, leading to iron deficiency
anemia (low MCV and low Hb)
• Choice A is incorrect because Schistosoma
haematobium infects bladder vasculature
• Choice B is incorrect because Schistosoma
eggs must hatch in freshwater
• Choice C is incorrect because Schistosoma
Photo Credit: CDC [Public domain]
spp. damage pulmonary vasculature, not
Figure 5.4.36 - Lateral spine on Schistosoma alveoli
haematobium egg
248

Section 25 - Clonorchis sinensis

1. Clones of orcs: Clonorchis sinensis 4. Goal stones: can cause pigmented gallstones
2. Tree with toads: trematodes 5. Workers collecting bananas with a pole: can cause
3. Orc eating raw fish: transmitted through cholangiocarcinoma
undercooked fish 6. Pretzels: treat with praziquantel

REVIEW QUESTIONS
1. A 64-year-old male with a 2-month history of
recurrent right upper quadrant abdominal pain
presents to a gastroenterologist for evaluation.
The patient states the pain is worse after he
eats and then recedes an hour later. Endoscopic
retrograde cholangiopancreatography (ERCP)
is recommended to evaluate the biliary tract.
During the procedure, the physician identifies
dark stones and removes them. A picture of
the procedure is shown below. Additional
evaluation suggests the patient’s pain was due
to a helminth infection. Which of the following
is true regarding the infectious organism?
Photo Credit: Samir (The Scope) at English Wikipedia [CC BY 2.5
(https://creativecommons.org/licenses/by/2.5)]
A. Transmitted via fish; treated with
praziquantel
B. Transmitted via fish; treated with
albendazole
C. Transmitted via pork; treated with
praziquantel
D. Transmitted via pork; treated with
albendazole
249
?
• Correct answer: A
• Biliary infection with Clonorchis sinensis
is most likely based on the following:
• Biliary colic (transient RUQ pain)
• ERCP revealing pigmented
gallstones
• Clonorchis sinensis is transmitted
through fish and treated with
praziquantel
• Choice B is incorrect because albendazole
does not treat Clonorchis sinensis
• Choice C is incorrect because Clonorchis
sinensis is not transmitted via pork
• Choice D is incorrect because Clonorchis
sinensis is not transmitted through pork or
treated with albendazole
250

Section 26 - Sarcoptes scabiei

1. Arm scab: Sarcoptes scabiei (scabies)
2. Swarming children: common in children
3. Red marker on children’s hands: infects interwebbed
spaces
4. Markered skin on dad: transmitted through skin-to-
skin contact
5. Dad scratching hands: causes pruritus
6. Baby with snake: creates serpiginous burrow lines
7. Layer of corn: burrow to the stratum corneum
8. Daughter with a perm: treat with permethrin
9. Smoke surrounding everyone: all household
members should be treated
10. Laundry: wash all bedding and clothing
 251

REVIEW QUESTIONS ?
1. A 35-year-old male presents to his family
physician with itching on his hands for 2 weeks.
The patient states that several of his children
have experienced similar symptoms recently.
Physical examination reveals several red
papules on the patient’s hand as shown below.
The physician writes a prescription for topical
permethrin. Which of the following should also
be considered as part of the management of
this patient’s condition?

Photo Credit: CDC [Public domain]

Figure 5.4.37 - Scabies-related erythematous
papules

Photo Credit: Wiki [Public domain]

A. Topical permethrin only for the

symptomatic children
B. Wash linens of only the symptomatic
children
C. Wash linens of each household member
D. Topical permethrin for entire household of
only symptomatic contacts

• Correct answer: C
• Scabies infection is most likely based on
the following:
• Pruritus
• Household members with similar
symptoms
• Papules on physical exam
• All household members should receive
topical permethrin and have linens
washed
• Choices A, B and D are incorrect because
these treatments exclude household
members that may have scabies
252
Section 27 - Pediculus corporis, pubis and capitis
1. Sign reading, “Teacher Pedicure Night”: Pediculus
species
2. Alien attacking the teacher’s head: Pediculus capitis
infests scalp hair
3. Particles from the hatched egg making the teacher’s
skin itchy: lice cause pruritus
4. Alien drinking spilled red nail polish: lice drink
human blood
5. Children coming to defend the school: school
attendance should not be disrupted
6. Alien eggs stabbed with knitting needles: lice eggs
are called nits
7. Child looking at pubic hairs on maturation poster:
Pediculus pubis infests pubic hair
8. Recon child suspended by armpits and waist:
Pediculus corporis infests the axilla and waist
9. Alien attack the teachers vinyl records: lice transmit
Borrelia recurrentis
10. Alien prowling: lice transmit Rickettsia prowazekii
11. Teacher yelling “Cortana” into her smartphone: lice
transmit Bartonella quintana
12. Girl with perm punching an alien: treat with
permethrin
13. Boys attacking alien eggs with school museum tusks:
treat with ivermectin
14. Confused principal ready for a marathon: treat with
malathion
 253

REVIEW QUESTIONS ?
1. A 13-year-old boy is brought to the physician
by his mother due to persistent dandruff. She
states that he has been constantly itching
his scalp for the past two weeks. Physical
examination reveals several small white
particles that are cemented securely to the
hair shaft. The physician also appreciates
several areas of excoriations on the scalp.
Which of the following is the most appropriate
Photo Credit: KostaMumcuoglu at the English Wikipedia [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0/)] recommendation for the patient?
Figure 5.4.38 - Pediculus capitis louse
A. Oral ivermectin
B. Exclusion from school activities until the
infection has been eradicated
C. Topical permethrin applied to the scalp
D. Topical malathion applied to the scalp and
pubic regions

• Correct answer: C
• Head lice with Pediculus capitis is most
Photo Credit: Gilles San Martin via Flickr likely based on the following:
Figure 5.4.39 - Pediculus nit on hair shaft • Pruritus with scalp excoriations
• Nits
• Head lice may be treated with topical
permethrin
• Choice A is incorrect because topical
ivermectin, not oral ivermectin, can treat
lice
• Choice B is incorrect because school
attendance should not be disrupted
• Choice D is incorrect because pubic lice
should not be suspected
Photo Credit: Ed Uthman from Houston, TX, USA [CC BY 2.0 (https://
creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
Figure 5.4.40 - Pediculus pubis louse

Photo Credit: Janice Harney Carr, Center for Disease Control [Public domain],
via Wikimedia Commons
Figure 5.4.41 - Pediculus corporis louse
254

VIRUSES

Figure 5.4.42 - Virus overview figure


Section 1 - Herpes simplex virus-1 (HSV-1) and herpes simplex virus-2 (HSV-2)
1. Hercules: Herpes simplex virus (HSV-1 & HSV-2)
2. Dark colors: DNA viruses
3. Two snakes moving out of temple: double stranded
4. Straight path to temple: linear
5. Mist: HSV-1 is transmitted through respiratory
droplets
6. Three gems on belt: HSV-1 remains latent in
trigeminal ganglion
7. Basset hound: HSV-1 may precipitate behçet
syndrome
8. Ginger in satchel: HSV-1 can cause gingivostomatitis
9. Carrots in satchel: HSV-1 can cause
keratoconjunctivitis
10. Hercules’ bloody finger: HSV-1 can cause herpetic
whitlow
11. Blood on snake lips: HSV-1 can cause herpes labialis
12. Red bite marks on arm: HSV-1 can cause erythema
multiforme
13. Red, bloody eyes: HSV-1 can cause retinitis
14. Craters: HSV-1 can cause ulcerated esophagitis
255
15. Temple on fire: HSV-1 can cause temporal lobe
encephalitis
16. “S” on clothing: HSV-2 is sexually transmitted
17. Torch: a TORCHES infection and can cause neonatal
herpes
18. Flames over crotch: HSV-2 can cause painful
vesicular genital lesions
19. Green beads: HSV-2 can cause inguinal
lymphadenopathy
20. Hat on fire: HSV-2 is more commonly associated
with meningitis
21. Sack of weapons: HSV-2 remains dormant in sacral
neural ganglia
22. 3 chains: diagnosed with PCR
23. Zeus with giant hammer: a Tzanck smear may reveal
multinucleated giant cells
24. Cow in cyclone: Cowdry A inclusions may be seen
25. Cyclone: treat with acyclovir
26. Violet-colored cyclone: treat with valacyclovir
27. Fan cyclone: treat with famciclovir
256

Photo Credit: Marco Mayer [CC BY-SA 4.0 (https://creativecommons.org/

licenses/by-sa/4.0)]
Figure 5.4.45 - Viral keratoconjunctivitis

Photo Credit: Henry Vandyke Carter [Public domain]

Figure 5.4.43 - Trigeminal ganglion

Photo Credit: James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.

org/licenses/by-sa/3.0)]

Photo Credit: James Heilman, MD [CC BY-SA 3.0 (https://creativecommons. Figure 5.4.46 - Herpetic whitlow
org/licenses/by-sa/3.0)]
Figure 5.4.44 - Gingivostomatitis
 257

Photo Credit: Courtesy of the U.S. Department of Health and Human Services
and Dr. Hermann
Figure 5.4.47 - Herpes labialis

Photo Credit: Donald E. Mansell, MD [CC BY-SA 3.0 (https://creativecommons.

org/licenses/by-sa/3.0)]
Figure 5.4.49 - HSV-related esophageal ulcers

Photo Credit: Grook Da Oger [CC BY-SA 3.0 (https://creativecommons.org/

licenses/by-sa/3.0)]
Figure 5.4.48 - Erythema multiforme
258

Photo Credit: SOA-AIDS Amsterdam [CC BY-SA 3.0 (https://creativecommons.

org/licenses/by-sa/3.0/)]
Figure 5.4.52 - Vesicular and ulcerative herpes
lesions

Photo Credit: Dr. Laughlin Dawes [CC BY 3.0 (https://creativecommons.org/

licenses/by/3.0)]
Figure 5.4.50 - MRI of temporal lobe encephalitis

Photo Credit: National Institute of Allergy and Infectious Diseases (NIAID)

[Public domain]
Figure 5.4.53 - Multinucleated giant cells on Tzanck
smear

Photo Credit: Kapitainekavern [CC BY-SA 4.0 (https://creativecommons.org/

licenses/by-sa/4.0)]
Figure 5.4.51 - Neonatal herpes

Photo Credit: Shaheen E. Lakhan and Lindsey Harle [CC BY 2.0 (https://
creativecommons.org/licenses/by/2.0)]
Figure 5.4.54 - Cowdry bodies in hepatocytes
 259

REVIEW QUESTIONS ?
1. A 14-year-old boy is brought to the emergency
department by his mother due to confusion
that began earlier today. His mother states
that he became lost at school even though
he has been at the same school for years. On
physical examination, he is disoriented to time,
place, and person. An MRI of the brain reveals
necrosis and hemorrhage of the temporal lobes
bilaterally. Which of the following is most likely
responsible for this patient’s condition?
A. DNA virus, double-stranded, linear, naked
B. DNA virus, single-stranded, linear, naked
C. DNA virus, double-stranded, linear,
enveloped
D. RNA virus, single-stranded, linear, naked,
positive-sense
E. RNA virus, single-stranded, linear,
enveloped, positive-sense

• Correct answer: C
• This patient has HSV-1 temporal lobe
encephalitis
• Confusion
• MRI that has revealed bilateral necrosis
and hemorrhage of the temporal lobes
• HSV is a DNA virus, double-stranded,
linear, enveloped
• A is describing Adenovirus which is not
associated with temporal lobe encephalitis
(it’s associated with rhinorrhea, pharyngitis,
and conjunctivitis)
• B is describing Parvovirus B19  which is a
single stranded DNA virus
• D is describing Picornaviruses  such as
Coxsackievirus which can cause meningitis
but not temporal lobe encephalitis
• E is describing Flaviviruses which can cause
encephalitis but are unlikely to cause
bilateral temporal lobe damage
260
Section 2 - Varicella-zoster virus (VZV)
1. Zoo: Varicella zoster virus (VZV)
2. Dark colors: DNA virus
3. Fighting animals with parallel antlers: double
stranded
4. Line of people leaving zoo: linear
5. Fog entering zoo: transmitted through respiratory
secretions
6. Chickens: causes chickenpox (pruritic vesicular rash)
7. Tree trunk: rash starts on the trunk
8. Zeus action figure: a Tzanck smear will reveal
multinucleated giant cells
9. Tree root: remains latent in ​the d
​ orsal root ganglia
10. Three gems on Zeus’ belt: remains latent in the
trigeminal ganglion
11. Monkey throwing shingles from roof: can cause
shingles
12. Woman hit with shingle in abdomen: presents as a
painful rash within a dermatomal distribution
13. Man hit with shingle in eye: may cause herpes
zoster ophthalmicus
14. Man hit with shingle in the foot: may cause
postherpetic neuralgia
15. Girl coughing because of dirt: can cause pneumonia
16. Husband pouring water on wife’s head: can cause
encephalitis
17. Torches: a TORCHES infection
18. Pregnant woman and little boy by torches:
congenital VZV
19. Scar on little boy’s cheek: congenital VZV can cause
dermatomal scarring
20. Boy wearing sunglasses: congenital VZV can cause
blindness
21. Boy holding stuffed bear with no arms or legs:
congenital VZV can cause limb hypoplasia
22. Live animals sign: live vaccine
23. BANDAID, syringe, and “Max Occupancy 200” sign:
the vaccine may be given to HIV patients when the
CD4+ count is greater than 200
24. Old man under pavilion: the vaccine is
recommended for those > 60 years old
25. Cyclone fan: treat with acyclovir
26. Violet cyclone fan: treat with valacyclovir
 261

REVIEW QUESTIONS ?
1. A 28-year-old male comes to the office due to
a rash that he first noticed yesterday. Physical
examination reveals a vesicular rash in a
dermatomal distribution on the patient’s trunk.
A viral infection is suspected. Which of the
following is an appropriate recommendation for
this patient’s condition?
A. Ganciclovir
B. Avoid contact with pregnant women
C. Supportive care
D. Prednisone

• Correct answer: B
• This patient has shingles caused by VZV
• Vesicular rash in a dermatomal
distribution
• Viral infection was suspected
Photo Credit: Mad Max [Public domain]
• VZV can be particularly devastating for
Figure 5.4.55 - Chickenpox pregnant women by harming the fetus
and causing congenital varicella →
patients who have an active infection
should avoid contact with pregnant
women
• A is incorrect because this is the treatment
for CMV
• C is incorrect because supportive care would
not be advised as this patient is presenting
early in the course of the infection and
Photo Credit: Elizgoiri [CC BY-SA 3.0 (https://creativecommons.org/licenses/ would likely benefit from treatment with
by-sa/3.0)]
acyclovir or valacyclovir
Figure 5.4.56 - Shingles • D is incorrect because glucocorticoids have
shown no clinical benefit in patients with
shingles

Photo Credit: Burntfingers [CC BY-SA 4.0 (https://creativecommons.org/

licenses/by-sa/4.0)]
Figure 5.4.57 - Herpes zoster ophthalmicus
262
Section 3 - Epstein-Barr Virus (EBV)
1. Elves Blue Village: Epstein-Barr virus
2. Dark colors: DNA virus
3. Female elf kissing booth: spread via saliva and
kissing
4. Elf falling asleep after kiss: causes fatigue
5. Elf pulling on collar: causes pharyngitis
6. Elf sticking out tongue with hairs: can cause oral
hairy leukoplakia
7. Hair curls behind ear and on neck: posterior
auricular and cervical lymphadenopathy
8. Cane with icosahedral gem: icosahedral capsid
9. BANDAID and “<500 kisses remain” sign: oral hairy
leukoplakia occurs at CD4+ levels of <500
10. Two ribbons hanging from lookout tower: double
stranded DNA virus
11. Line for kissing booth: linear virus
12. Fighting with T-shaped flails: cytotoxic T cells seen
on peripheral smear
13. “No Contact Sports” sign: avoid contact sports for
3-4 weeks due to rupture of enlarged spleen
14. Bow shooting arrows at the stars: heterophile
antibodies
15. Light spotting arrows in the sky: monospot positive
16. Arrow through nose of the villain: can cause
nasopharyngeal B-cell carcinoma
17. Net with knots trapping elves with pink cancer
ribbons: can cause lymphoma
18. Elf holding bucket full of arrows: can cause Burkitt’s
lymphoma (B-cell lymphoma)
19. Sky full of stars: starry sky appearance on biopsy of
Burkitt’s lymphoma
20. Villain shocking brain with electric rings: can cause
primary central nervous system lymphoma which
exhibits ring-enhancing lesions on imaging
21. Elf holding up $100 bill: primary central nervous
system lymphoma occurs in HIV when CD4+ cells are
<100
 263

REVIEW QUESTIONS ?
1. A 15-year-old obese girl presents to the clinician
with a fever and a sore throat. Upon further
discussion, the girl states that she has felt tired
for the past several days. She has felt healthy
prior to this illness and does not complain of
any other symptoms. Physical examination does
Photo Credit: Ed Uthman via Flickr not reveal any noticeable organomegaly in the
Figure 5.4.58 - Cytotoxic T-cells on EBV-related left upper quadrant of her abdomen. Her blood
peripheral blood smear is drawn and a lab test confirms the presence of
heterophile antibodies. Which of the following
is most likely true about her condition?
A. The patient had a sexual encounter before
acquiring the infection
B. A double-stranded RNA virus is the likely
pathogen
C. The patient may have a lymphocytic
neoplasm in her brain
D. She should avoid contact sports for at least
3 weeks

• Correct answer: D
• The patient likely has an EBV infection
based on the following findings:
• Fever, sore throat, fatigue
• Positive heterophile (monospot)
test
• Though this patient does not have
evidence of splenomegaly, the risk of
splenomegaly is still high enough that
Photo Credit: Louis M. Staudt by NIH [Public domain]
she should be advised to avoid contact
Figure 5.4.59 - Starry sky appearance on biopsy of sports for at least 3 weeks
Burkitt’s lymphoma • Choice A is incorrect because EBV is not
sexually transmitted
• Choice B is incorrect because EBV is a
double-stranded DNA virus
• Choice C is incorrect because EBV does
not cause primary central nervous system
lymphoma in immunocompetent patients

Photo Credit: Aimun AB Jamjoom, Abrar R. Waliuddin and Abdulhakim B.

Jamjoom [CC BY 2.5 (https://creativecommons.org/licenses/by/2.5)]
Figure 5.4.60 - MRI showing ring-enhancing lesion
264
Section 4 - Cytomegalovirus (CMV)
1. Megatronix: Cytomegalovirus (CMV)
2. Dark colors: DNA virus
3. Two parallel ladders: double stranded
4. Straight road with dashed lines down the middle:
linear
5. Sleeping robot with bow and T-shaped flail near
nuclear power plant: CMV becomes latent in B cells,
T cells, and mononuclear cells
6. Optimum prime scraping lines in building over
50mph sign: increased risk of linear esophagus
ulcers in HIV patients when the CD4+ <50 cells/
microL
7. Laser beams from eyes: increased risk of retinitis in
HIV patients when the CD4+ <50 cells/microL
8. Gutter going up in flames: increased risk of colitis in
HIV patients when the CD4+ <50 cells/microL
9. Exploding fire hydrant pouring water on man’s head:
increased risk of encephalitis in HIV patients when
the CD4+ <50 cells/microL
10. Lung-shaped axe and transplant guy: may cause
pneumonitis in transplant patients
11. Torches on balcony: a TORCHES infection
12. Mom eating blueberry muffin: congenital CMV may
cause a “blueberry muffin” rash
13. Lazy Dalmatian dog with liver spot:
hepatosplenomegaly
14. Baby wearing earmuffs: congenital CMV may cause
deafness
15. Parrot causing milk to spill on baby’s head:
congenital CMV may cause periventricular
calcifications
16. Baby holding stuffed penguin: congenital CMV may
cause microcephaly
17. Mother wearing sunglasses: congenital CMV may
cause chorioretinitis
18. Broken spotlight: negative monospot test
19. Halos around laser beam: infected cells may show
intranuclear and intracytoplasmic inclusions with a
surrounding halo (owl’s eyes)
20. Fast car: treat with foscarnet
21. Garbage can: ganciclovir
22. Violet garbage can: valganciclovir
 265

Photo Credit: CDC/Dr. Edwin P. Ewing, Jr. [Public domain]

Figure 5.4.64 - Owl’s eye appearance on lung biopsy
Photo Credit: https://ww.nei.nih.gov/photo/eyedis/index.asp [Public domain]
Figure 5.4.61 - CMV retinitis
REVIEW QUESTIONS ?
1. A 24-year-old female presents to her physician
for results regarding a monospot test. A week
ago she developed pharyngitis and cervical
lymphadenopathy so a monospot test was
performed and the results were negative. She
is 19 weeks pregnant with her second child
and is concerned about the implications of the
test. The physician suspects that her illness
was caused by a double-stranded, linear, DNA
virus. He counsels her that the unborn child
is at greatest risk for developing which of the
following?
Photo Credit: CDC [Public domain]
Figure 5.4.62 - “Blueberry muffin” rash A. Retinitis pigmentosa
B. Patent ductus arteriosus
C. Vesicular lesions on the scalp
D. Hepatosplenomegaly

• Correct answer: D
• This woman had a CMV infection during
pregnancy
• Pharyngitis
• Cervical lymphadenopathy
• Negative monospot test
• Double-stranded, linear, DNA virus
• 19 weeks pregnant so a CMV infection
during pregnancy puts the unborn child
at risk of developing congenital CMV →
hepatosplenomegaly
• A is incorrect because congenital CMV
can cause chorioretinitis but not retinitis
pigmentosa
• B is a reference to congenital Rubella, but
this is a single stranded RNA virus
Photo Credit: Adriano R. Tonelli1, Kalyan Kosun1, Sainan Wei2 and Davoren • C is a reference to congenital HSV, but this
Chick1 [Modified] would present with a painful vesicular rash
Figure 5.4.63 - Periventricular calcifications on CT on the genitals in the mother
imaging
266

Section 5 - Roseola (HHV-6 and HHV-7)

1. Creepy baby doll holding roses: Roseola
2. Dark colors: DNA virus
3. Char on baby from head to toe: widespread
maculopapular rash
4. Oil lamp causing tall flames: high fevers
5. Salivating dog knocking over lamp: transmitted
through saliva
6. Line of slobber: linear virus
7. Two strands of yarn: double-stranded
8. “666” on side of trunk: HHV-6
9. Bulletin board with “7 deadly sins” list: HHV-7
10. Shaking telephone: seizures
 267

REVIEW QUESTIONS ?
1. A 13-month-old girl presents to her pediatrician
with a red “rash” all across her body for 1 day.
Her temperature in the clinic is 37.9 C and
the patient appears mildly uncomfortable.
Upon further history, the father explains the
patient had a temperature of 39.9 C at home
4 days ago. Around this time the patient
also demonstrated a 30 second period of
unresponsiveness, uncontrollable shaking
movements and open eyelids. The physician
suspects a viral infection. Which of the following
is most likely true regarding the virus?
A. It is an RNA virus
B. It is a naked virus
C. The genome is circular
D. It is double-stranded

• Correct answer: D
• The patient likely has a Roseola
infection (HHV-6) based on the
following:
• High fever
• Seizure followed by a rash 3 days
later
• HHV-6 is double-stranded
• Choice A is incorrect because HHV-6 is a
DNA virus, not an RNA virus
• Choice B is incorrect because HHV-6 is
enveloped, not naked
• Choice C is incorrect because HHV-6 is has a
linear genome, not circular
268

Section 6 - Kaposi sarcoma (HHV-8)

1. Dark colors: DNA virus
2. Bones show that sirens ate the sailors: HHV-8
3. Sailors lined up on boat: linear virus
4. Red and purple lesions on evil sirens: dark purple
skin plaques formed by endothelial neoplasia
5. Cancer ribbons near dead camels: Kaposi sarcoma
6. Stretcher: immunocompromised patients vulnerable
to Kaposi sarcoma
7. Two lines of dirt caused by stretcher: double
stranded
 269

REVIEW QUESTIONS
1. A 35-year-old male presents with dark purple
 
Photo Credit: National Cancer Institute, AV-8500-3620 [Public domain]
Figure 5.4.65 - Skin lesions in Kaposi’s sarcoma
?
plaques all over his hands and arms. He states
the rash started a few months ago on his hands
and has continued to spread up his arms. The
patient endorses a 15-year history of having
regular, unprotected sexual intercourse with
prostitutes. A lymphocyte CD4+ count reveals
a level of 350 cells/mm3. Biopsy of a skin
lesion reveals numerous lymphocytes. Gram
staining and blood cultures do not grow any
organisms. Which of the following is most
likely true regarding the cause of this patient’s
presentation?
A. The purple plaques are caused by a single-
stranded virus
B. Healthy patients can acquire the infection
with similar symptoms through direct
contact with the skin plaques
C. A gram negative organism caused the skin
findings
D. He would likely be asymptomatic if his CD4+
count was 1,200 cells/mm3

• Correct answer: D
• Kaposi sarcoma is likely based on the
following:
• Purple plaques that have spread
• CD4+ count of 350 cells/mm 3

• HHV-8 does not cause symptoms

in patients with adequate immune
systems (eg, patients with CD4+ counts
> 1,000 cells/mm 3

• Choice A is incorrect because HHV-8 is

double-stranded
• Choice B is incorrect because skin plaques
will not infect immunocompetent patients
• Choice C is incorrect because a sample
would likely have shown Bartonella
hensalae, a gram negative organism known
to cause bacillary angiomatosis in AIDS
patients
270
Section 7 - Hepatitis B Virus (HBV)
1. Cows with liver spots being attacked by killer bees:
Hepatitis B virus
2. Hip pads: hepadnavirus
3. Arrows shot into the beehive surface: Anti-HBs
antibodies confer immunity
4. Surface antigens injected through needle: the
vaccine contains HBs antigens
5. Partially double-file circle of men: circular and
partially double-stranded genome
6. Toxic green glowing goop on T-shaped flail: cytotoxic
T-cells cause liver damage
7. Shards of glass on the ground: liver biopsy shows
ground glass appearance
8. Icosahedral-shaped core: icosahedral capsid
9. Bees actively attacking man stealing gems at the
core of the beehive: HBcAg indicates active infection
10. Old man among gems: Anti-HBc indicates old,
resolved infection
11. Mountain of gems at core with “e” shaped bee
larvae: HBeAg indicates high viral replication and
infectivity
12. Archer attacking “e” shaped larvae: Anti-HBe
antibodies indicate low replication and infectivity
13. Man stealing gems getting actively attacked by a
bee: HBsAg indicates active infection
14. Marksman pinning bee to surface of hive near gems:
Anti-HBs antibodies indicate resolved infection or
vaccination
15. Woman wearing scarlet letter: transmission through
sexual intercourse
16. Pregnant woman: transplacental transmission
17. Woman with IV drip: transmission through IV drug
use
18. Long branch with bird’s nest full of eggs: long
incubation period
19. Cow with liver spot stuck in gnarled tree branches:
chronic infection can cause liver cirrhosis
20. Pink ribbon around cow: cirrhosis can lead to
hepatocellular carcinoma
21. Pink ribbon around cow not stuck in the tree:
chronic hepatitis B can lead to hepatocellular
carcinoma even in the absence of cirrhosis
22. Bee unable to lift cow out of stable: chronic and
stable infections possible
23. Dark, dead cow: fulminant liver failure with necrosis
is possible during acute phase
24. Cows with scratches and scrapes: acute hepatitis
can cause rashes and arthralgia
25. Oil lamp hanging from tree branch: acute hepatitis
can cause fever
26. Cow drenched in honey: acute hepatitis can cause
jaundice
27. Unharmed cow and happy boy: acute hepatitis can
be asymptomatic
 271

28. Lots of cows with rash and arthralgia: acute
hepatitis with resolution is the most common
outcome
29. Unharmed cow being carried by bee: carrier state is
common
30. Red ropes around man’s abdomen: associated with
polyarteritis nodosa
31. Balloons of various colors popped while still inside
net: associated with aplastic anemia
32. Kidney beans and arrows blocking rain
gutter: associated with membranous
glomerulonephropathy
33. Frayed, growing rain gutter: associated with
membranoproliferative glomerulonephropathy
34. Water well with one rope becoming two ropes:
hepatitis B has reverse transcriptase
35. Sheep dogs rescuing cows: hepatitis D relies on
hepatitis B virus to infect host cells

Figure 5.4.66 - HBV structure

Serologic Marker Description and Role

• Surface glycoprotein
HBsAg • Present in acute infection
• If present > 6 months → infection is considered chronic
• HBV polypeptide between core and surface
• Present in acute infection as well as early chronic patients
HBeAg
• Indicates high viral replication
• Indicates patient is highly contagious
• Present in acute infection
Anti-HBc IgM
• Present in window phase
• Indicates immunity
Anti-HBs • Present in recovered patients
• Present in vaccinated patients
• Indicates low viral replication
Anti-HBe • Indicates patient is not very contagious
• Present in recovered patients as well as late chronic patients

Anti-HBc IgG • Present after ~6 months in both chronic or fully recovered patients

Table 5.4.1 - Descriptions of serologic markers in Hepatitis B

272

Figure 5.4.67 - Serological markers in acute hepatitis B infection

Figure 5.4.68 - Serological markers in chronic hepatitis B infection


REVIEW QUESTIONS
1. A 35-year-old male presents with dark purple
Photo Credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/
by-sa/3.0)]
Figure 5.4.69 - H&E stain showing ground glass
appearance
I. Clinical outcomes of Hepatitis B (heading)
A. Acute infection that resolves within 6 months
(most common)
1. May have arthralgias, rash, fever, jaundice
2. May be asymptomatic (anicteric)
B. Fulminant liver failure and hepatic necrosis
C. Chronic infection (stable)
D. Chronic infection → cirrhosis
E. Chronic infection → cirrhosis → hepatocellular
carcinoma
F. Chronic infection → hepatocellular carcinoma
Figure 5.4.70 - Reverse transcriptase in HBV
273
?
plaques all over his hands and arms. He states
the rash started a few months ago on his hands
and has continued to spread up his arms. The
patient endorses a 15-year history of having
regular, unprotected sexual intercourse with
prostitutes. A lymphocyte CD4+ count reveals
a level of 350 cells/mm3. Biopsy of a skin
lesion reveals numerous lymphocytes. Gram
staining and blood cultures do not grow any
organisms. Which of the following is most
likely true regarding the cause of this patient’s
presentation?
A. The purple plaques are caused by a single-
stranded virus
B. Healthy patients can acquire the infection
with similar symptoms through direct
contact with the skin plaques
C. A gram negative organism caused the skin
findings
D. He would likely be asymptomatic if his CD4+
count was 1,200 cells/mm3
• Correct answer: C
• Vaccinated patients should have
antibodies against the HBsAg
• Anti-HBc antibodies are only present in
previously infected patients
• HBeAg is only present in patients during
an active infection
• Choice A is incorrect because this patient
should be negative for anti-HBc and HBeAg
• Choice B is incorrect because this patient
should be positive for anti-HBs and negative
for anti-HBc
274
Section 8 - Smallpox, Cowpox, and Molluscum contagiosum
1. Boxes: pox viruses
2. Blue background: DNA virus
3. Boxes outside of sandbox: replication in cytoplasm
4. Small boxes: smallpox virus is a poxvirus
5. Child burying boxes: smallpox virus has been
eradicated
6. Sandy slug: molluscum contagiosum is a pox virus
7. Deep hole in sand next to slug: Molluscum
contagiosum causes umbilicated skin lesions
8. Cow being milked: Cowpox (“milkmaid blisters”) is a
poxvirus
9. Two parallel slides: double stranded
10. Brick in sand box: brick-shaped
11. Kids waiting in line for milk: linear
12. Map of the world: largest DNA viruses in the world
13. Live animals sign: live attenuated vaccine
 275

Photo Credit: Gzzz [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-

sa/4.0)], from Wikimedia Commons
Figure 5.4.72 - Umbilicated lesions in Molluscum
contagiosum

Photo Credit: https://en.wikipedia.org/wiki/File:Child_with_Smallpox_

Bangladesh.jpg
Figure 5.4.71 - Smallpox

REVIEW QUESTIONS ?
1. A 4-year-old boy is brought to the physician • Correct answer: C
due to a 3-day history of a rash. The boy’s • This boy has an infection caused by
mother states that she first noticed the rash Molloscum contagiosum
when she picked him up from daycare. Physical • Small papules with central areas of
examination of the left arm reveals clusters of depression (umbilicated lesions)
small papules with central areas of depression. • Molloscum contagiosum is enveloped
Which of the following is most likely true • A is wrong because poxviruses are DNA
regarding the causal organism? viruses
• B is wrong because poxviruses are double
A. It is a RNA virus
stranded
B. It is single stranded
C. It is enveloped • C is wrong because poxviruses replicate in
D. It replicates in the nucleus of infected cells the cytoplasm of infected cells
276
Section 9 - Human papillomavirus
1. Pepsi: Human papillomavirus (HPV)
2. Blue colors: DNA virus
3. Grape vines wrapped in circle: circular genome
4. Two parallel grape vines: double-stranded
5. Naked baby: naked virus
6. Cauliflower row with 1 plant, row with 2 plants, row
with 6 plants, and row with 2 tall plants: serotypes
1, 2, 6, and 11 are associated with warts
7. Car keys, “I voted” sticker, and woman with cancer
hope ribbon near crotch: serotypes 16 and 18 are
associated with cervical cancer
8. Barefoot guy picking cauliflower in first two rows:
serotypes 1 and 2 are associated with verrucae on
the hands and feet
9. Cucumbers next to rows that represent serotypes
6 and 11: serotypes 6 and 11 cause condyloma
acuminatum
10. Baby eating ladybugs near rows representing
serotypes 6 and 11: serotypes 6 and 11 can cause
laryngeal papillomas
11. Indy 500 tattoo and Band-Aid: HIV patients have an
increased risk of anal and cervical cancer when CD4
cell count <500
12. “7” shaped straw: serotypes 16 and 18 produce E7
(a protein associated with cancer)
13. 6 pack of Pepsi: serotypes 16 and 18 produce E6 (a
protein associated with cancer)
14. Rotten tomatoes with big brown spots near
rows that represent serotypes 6, 11, 16, and 18:
Koilocytes may be seen in patients with an HPV
infection from serotypes 6, 11, 16, or 18
15. Syringe shaped sign pointing towards serotypes 6,
11, 16, and 18: the Gardasil vaccine can prevent
infection from serotypes 6, 11, 16, and 18
 277

Photo Credit: Marionette [CC BY-SA 3.0 (https://creativecommons.org/

livenses/by-sa/3.0)]
Figure 5.4.73 - Plantar warts

Photo Credit: Colorectal at Greek Wikipedia Aπόστολος Σταματιάϭης [CC BY-

SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]
Figure 5.4.74 - Anal warts
278

Figure 5.4.75 - HPV carcinogenesis mechanism

Photo Credit: Photomicrograph by Ed Uthman, MD, 20 July 2006 Euthman

20:24, 29 November 2006 (UTC) [Public domain]
Figure 5.4.75 - Koilocytes on Pap smear
 279

REVIEW QUESTIONS ?
1. A 5-year-old boy is brought to the physician
due to shortness of breath and wheezing that
began 20 minutes ago. Physical examination
is significant for nasal flaring and subcostal
retractions. Laryngoscopy reveals a benign
laryngeal tumor occluding the airway. The
tumor is excised and a pathological report states
that the histological changes were caused by
a virus. Which of the following is most likely
responsible for this patient’s condition?
A. RNA virus, single-stranded, positive-sense
B. RNA virus, single-stranded, negative-sense
C. DNA virus, double-stranded, non-enveloped
D. DNA virus, double-stranded, enveloped
E. DNA virus, single-stranded, non-enveloped

• Correct answer: C
• This patient has a laryngeal papilloma
caused by HPV resulting in a compromised
airway
• Shortness of breath, wheezing, and a
benign laryngeal tumor occluding the
airway
• The changes were caused by a virus
• HPV is a DNA virus, double-stranded,
and non-enveloped
• A and B are incorrect because most RNA
viruses are single-stranded and either
positive or negative sense, but a laryngeal
papilloma in a child is a unique finding to
HPV which is a DNA virus
• D is incorrect because most DNA viruses are
double-stranded and many are enveloped
such as HSV and poxviruses, but these are
not associated with laryngeal papillomas
• E is incorrect because the only DNA virus
that is single stranded is parvovirus, but is
not associated with laryngeal papillomas
280
Section 10 - Adenovirus
1. Adam: Adenovirus
2. Blue colors: DNA virus
3. Two serpents slithering up the tree: double
stranded
4. Line of people waiting for seats: linear
5. Naked Adam and Eve: naked (non-enveloped)
6. Crowded audience wearing camouflage: outbreaks
in crowded quarters (eg, military recruits)
7. Juicy pomegranate full of seeds: hemorrhagic
cystitis
8. Adam with red eyes: can cause conjunctivitis
9. Adam coughing: can cause pneumonia
10. Eve wearing handkerchief: can cause pharyngitis
11. Watery river: can cause watery diarrhea
12. Raspberry patches: may cause Peyer patch
hypertrophy
13. Telescope: can cause intussusception
14. Muscly bouncer guy with car tattoo: can cause
myocarditis
15. Live show sign shaped like a syringe: live vaccine
 281

REVIEW QUESTIONS ?
1.  A 3-year-old boy is brought to the emergency
department due to sudden onset abdominal
pain. The episodes are severe but intermittent
and occur approximately every 15-20 minutes.
The mother also states that just before coming
to the hospital she saw red stools in the toilet
after her son had a bowel movement. After
appropriate management the family is informed
that the patient’s condition was most likely due
to a viral infection. This causal organism is also
associated with which of the following?
A. A purpuric rash
B. Aplastic anemia
C. Nasopharyngeal carcinoma
D. Hemorrhagic cystitis

• Correct answer: D
• This boy’s presentation is due to
intussusception caused by Adenovirus
• He is 3 years old and intussusception is
most common in young children
• He has had intermittent episodes of
abdominal pain and red stools
• His condition was most likely due to
a viral infection, and intussusception
commonly occurs following a viral
infection (most commonly Adenovirus)
• Adenovirus is also associated with
hemorrhagic cystitis
• A is a reference to Henoch-Schönlein
purpura which is a small-vessel vasculitis
that is associated with intussusception, but
this not a viral infection
• B is a reference to Parvovirus B19 which
can cause aplastic anemia in sickle cell
patients but this is not a typical feature of
adenovirus
• C is a reference to EBV which can cause
pharyngitis and posterior cervical
lymphadenopathy but isn’t typically
associated with intussusception
282

Section 11 - JC Virus and BK Virus

1. Polly the bird: Polyomavirus
2. Burger King and JC Penney signs: BK virus and JC
virus are polyomaviruses
3. Blue colors: DNA virus
4. Circular shaped Christmas lights decorating an arch:
circular DNA structure
5. Parallel pine decorations: double-stranded DNA
genome
6. Naked mannequins: naked virus
7. “Try our new kidney bean veggie burger” sign: BK
virus targets the kidneys
8. Butcher with meat: BK virus infects transplant
patients
9. Juicy pomegranate full of seeds: BK virus causes
hemorrhagic cystitis
10. Sleeping employee: JC virus becomes latent
11. Girl with a band-aid on her arm: JC virus is
commonly associated with AIDS patients
12. Receipt for $200: reactivation doesn’t occur until
CD4+ cell count <200
13. Polka dot veil: JC virus causes progressive multifocal
leukoencephalopathy
14. MRI in front of sleeping employee: MRI shows non-
enhancing areas of demyelination
15. Nat King Cole CD’s: Natalizumab increases risk of
PML
 283

REVIEW QUESTIONS ?
1. A 27-year-old female comes to the office due
to a 3-day history of dysuria and hematuria.
One year ago she underwent major surgery for
a left kidney transplant. Physical examination
is unremarkable. Laboratory evaluation reveals
an elevated serum creatinine. A kidney biopsy
reveals intranuclear basophilic viral inclusions
without a surrounding a halo. PCR analysis
of the patient’s plasma confirms that her
Photo Credit: Hellerhoff [CC BY-SA 3.0 (https://creativecommons.org/ symptoms are due to a viral infection. What is
licenses/by-sa/3.0)], from Wikimedia Commons
the most likely diagnosis?
Figure 5.4.77 - Progressive multifocal
leukoencephalopathy (PML) on MRI A. CMV
B. BK virus
C. JC virus
D. Delta virus

• Correct answer: B
• This patient has hemorrhagic cystitis due to
a BK virus infection
• Dysuria and hematuria after a left
kidney transplant → hemorrhagic
cystitis
• BK virus commonly targets the kidneys
and causes hemorrhagic cystitis in
kidney transplant patients
• A is incorrect because the biopsy revealed
intranuclear basophilic viral inclusions
without a surrounding halo (CMV can
result in infection among transplant
patients but a biopsy would have revealed
the characteristic “owl eye” intranuclear
inclusions)
• JC virus is a polyomavirus just like BK virus
but it causes PML in AIDS patients
• D is referring to hepatitis D virus (commonly
associated with hepatitis B coinfections)
284
Section 12 - Parvovirus B19
1. Parfaits: Parvovirus B19
2. Blue colors: DNA virus
3. Hummingbird (small bird): smallest DNA virus
4. Kids lined up to see bird: linear
5. Silly string: single stranded
6. Skinny dippers: naked
7. Steam from hot tub: transmitted through
respiratory droplets
8. Red balloons in enclosed area: replicates in red
blood cell precursor cells in bone marrow
9. Bully slapping child with plastic hand: causes fifth
disease (erythema infectiosum) which presents with
an erythematous rash on the cheeks (“slapped-
cheek”)
10. Girl wearing lacy shirt: causes a lacy, reticular rash
on the trunk and extremities
11. Kid popping balloons with a sickle: can cause
aplastic crises in sickle cell patients
12. Muscle man in car: can cause myocarditis
13. Basset hound: can precipitate behçet syndrome
14. Woman reaching for toy with sore knees: can cause
arthralgias and arthritis in adults
15. Torch: a A TORCHES infection
16. Pregnant woman in hot tub: pregnant woman can
contract the disease

REVIEW QUESTIONS
1. A 9-year-old boy with a history of sickle
Photo Credit: Andrew Kerr [Public domain]
Figure 5.4.78 - Fifth disease
285
?
cell disease is brought to the emergency
department due to shortness of breath.
Several days ago he developed a fever, malaise,
and myalgias. Physical examination reveals
conjunctival pallor. Laboratory analysis is
significant for a hematocrit of 27% (normal:
40%) and a reticulocyte count of 0.2% (normal:
0.5% - 1.5%). The medical team concludes that
this patient’s condition is due to a pathogen
that most likely replicates in which of the
following cell types?
A. B cell precursors
B. Erythrocyte precursors
C. T cell precursors
D. Macrophage precursors
• Correct answer: B
• This boy has an aplastic crisis caused by
Parvovirus B19
• History of sickle cell disease
• Developed a fever, malaise, and
myalgias which was likely due to a viral
infection
• His presentation at the ED has shown
conjunctival pallor → anemia
• Laboratory results showing a decreased
hematocrit and reticulocyte count (the
bone marrow is unable to adequately
produce reticulocytes)
• Parvovirus B19 replicates in erythrocyte
precursors in the bone marrow,
resulting in abnormal erythrocyte
production and a transient aplastic crisis
• Many viruses replicate in lymphocytes such
as HIV but these are not associated with
aplastic crises (A and B)
• Bacteria such as TB replicate in
macrophages (D)
286

Section 13 - Coronavirus and SARS

1. Warm colors: RNA virus 5. Corkscrew bottle opener: helical capsid

2. Rainbow: positive sense 6. SARS shirt: causes severe acute respiratory
3. Sick, cold man: common cold virus syndrome (SARS)
4. Corona beer: coronavirus 7. Man out of breath: respiratory distress
 287

REVIEW QUESTIONS ?
1. A 15-year-old girl presents to the physician
with a mild headache and nasal congestion for
2 days. She states that everyone in her family
has had similar symptoms recently. On physical
examination, her throat appears red with visible
mucus drainage. Her temperature is 37.8 C
and she appears mildly uncomfortable. A rapid
streptococcal antigen test is negative and a viral
PCR panel is negative for rhinovirus. Which of
the following statements is true regarding the
most likely causal organism?
A. The pathogen carries its own DNA
polymerase
B. The capsid has an icosahedral shape
C. The pathogen has a lipid bilayer surrounding
its genome
D. The genetic material is double-stranded

• Correct answer: C
• The patient most likely has an infection
with coronavirus because of the
following:
• Pharyngitis, nasal congestion,
headaches, and mucus drainage
• No evidence of S. pyogenes
• No evidence of rhinovirus
• Coronavirus is enveloped
• Choice A is incorrect because negative sense
viruses carry their own RNA polymerase,
not positive sense viruses
• Choice B is incorrect because coronavirus
has an icosahedral capsid
• Choice D is incorrect because coronavirus is
a single-stranded RNA virus
288
Section 14 - Human immunodeficiency virus (HIV)
1. Woman with wounds covered by Band-Aids: Human
immunodeficiency virus (HIV)
2. Red and orange colors: RNA virus
3. Pulley: retrovirus (reverse transcriptase)
4. One red rope splitting into two blue ropes: reverse
transcriptase converts a single strand of RNA into
double stranded DNA
5. Rainbow: positive sense virus
6. Line of soldiers: linear
7. Mirror: has a diploid genome (two copies of RNA)
8. Captured dwarf eating ice cream cone: cone-shaped
capsid
9. Gagged dwarf: the gag gene encodes for the capsid
(p24)
10. Wizard casting a matrix spell with the number 17:
the gag gene encodes for the matrix (p17)
11. Metal poles near pulley: the pol gene encodes for
reverse transcriptase
12. Metal poles near scissors: the pol gene encodes for
aspartate protease
13. Metal poles near dwarf tying ropes together: the pol
gene encodes for integrase
14. “Envious” on dress: the env gene encodes for gp160
which becomes gp120 and gp41
15. 160 soldiers split into a group of 120 and a group of
41: gp160 is cleaved to form gp120 and gp41
16. Group of 41 soldiers using battering ram to enter
building: gp41 is associated with viral fusion and
entry into host cell
17. Group 120 soldiers climbing ladder and pulling
down servant helper with the number “4” on his
shirt: gp120 binds to CD4 receptor
18. Scarlet letter: sexually transmitted
19. T-shaped flail held by a sexy girl wearing “CXR4”:
infects CD4 T cells using the CXCR4 coreceptor
20. Guy playing guitar with CCR5 shirt on top of cage:
infects macrophages using the CCR5 coreceptor
21. CCR band member resisting opposing soldiers: CCR5
coreceptor mutations confer resistance or immunity
to HIV
22. Servant suffocating and holding neck: the initial
infection may present with pharyngitis
23. Lamp: the initial infection may present with a fever
24. Green beaded net: the initial infection may present
with lymphadenopathy
25. Sleeping soldier: there is a period of latency
following the initial infection
26. "200 feet drop” sign: AIDS is diagnosed when the
CD4+ cell count is <200
27. Person trapped in green net, with shocked brain,
and wearing a cancer ribbon: can cause primary
central nervous system lymphoma (imaging may
show ring-enhancing lesions)
28. Torches: a TORCHES infection

29. Soldier wearing belt made of gems and pointing
arrow at dwarf holding sundial: diagnosed with a
combined immunoassay (detects HIV antibodies
and the p24 antigen) followed by a differentiation
immunoassay (detects HIV antibodies)
30. Wheelbarrow full of Band-Aids: a viral load may be
obtained using NAAT
31. Crossed out baby sign next to immunoassay soldier:
the antibody/antigen immunoassay test should not
be performed on babies (only use viral load)
32. Skull on front of wheelbarrow: a high viral load is
associated with a poor prognosis and may be lethal
Figure 5.4.79 - HIV structure
289
33. Pregnant dwarf lady with sitting dove: pregnant
women with HIV should receive zidovudine
34. Two soldiers inhibiting dwarf from using well, one
soldier inhibiting dwarf from tying the ropes: the
initial regimen for HIV typically includes 2 NRTIs and
an integrase inhibitor
35. Soldier next to 200 sign holding meth crystals:
TMP-SMX prophylaxis is administered when the CD4
count drops below 200
36. Scarecrow with U.S. map of 50 states shirt:
macrolide prophylaxis is administered when the CD4
count drops below 50
290

Figure 5.4.80 - HIV replication cycle

Figure 5.4.81 - Time course of HIV infection


Figure 5.4.82 - HIV diagnosis
REVIEW QUESTIONS
1. A novel drug is being developed to treat HIV.
An in vitro experiment is performed by adding
HIV on a medium containing the novel drug and
isolates of cultured human CD4 T lymphocytes.
Further analysis reveals that in the presence
of the drug the virus is unable to attach to the
cellular membrane. Which of the following is
the most likely target of this drug?
A. CXCR4
B. CCR5
C. gp120
D. gp41
291
?
• Correct answer: C
• Reasons why C is correct:
• The novel drug makes it so the virus
is unable to attach to the cellular
membrane of CD4 T lymphocytes
• gp120 interacts with the CD4 receptors
which allows the virus to attach to the
cell membrane
• A is incorrect because CXCR4 is the
coreceptor on CD4 T lymphocytes that
interacts with gp120 and induces a
conformational change in gp120 (viral entry
into the host cell)
• B is incorrect because CCR5 is similar to
CXCR4 but is present on macrophages
instead of T lymphocytes
• D is incorrect because gp41 is responsible
for fusion and entry (the virus can still bind
to the cell membrane without this receptor
- it just can’t enter the host cell)
292
Section 15 - Human T-lymphotropic virus (HTLV)
1. T-shaped flail in knight’s hand: Human
T-lymphotropic virus
2. Retrograde pulley: retrovirus (reverse transcriptase)
3. Warm colors: RNA virus
4. Line of people: linear and single stranded
5. No naked people: enveloped
6. Mirror: two copies of RNA
7. Icosahedral-shaped water containers: icosahedral-
shaped capsid
8. Rainbow: positive sense
9. Cancer ribbon on t-shaped flail covered in blood:
causes adult T-cell leukemia-lymphoma
10. Japanese samurai, west African guy, & pirate from
the Caribbean: more prevalent in Japan, West
Africa, and the Caribbean
11. Medicinal vials: associated with IV drug use
12. Old guy with cane: HTLV can cause slowly
progressive weakness
13. West African guy with bottle of milk: adult T-cell
lymphoma can cause hypercalcemia
14. Man with skin lesion: adult T-cell lymphoma causes
cutaneous lesions
15. Lung-shaped axe: adult T-cell lymphoma can cause
pulmonary infiltrates
16. Well made of bones: adult T-cell lymphoma can
cause lytic bone lesions
 293

REVIEW QUESTIONS ?
1. A 44-year-old male comes to the office due to a
rash. His medical history is significant for recent
travel to the Caribbean for a business-related
trip. Physical examination reveals a generalized
papular rash and lymphadenopathy. Laboratory
analysis is significant for hypercalcemia and
an elevated white blood cell count. Imaging
reveals lytic bone lesions. The pathogenesis of
this patient’s condition is thought to be due to
constitutive activation of the JAK-STAT pathway
and inactivation of the tumor suppressor
TP53. Which of the following is most likely true
regarding this patient’s condition?
A. It’s caused by a single stranded linear RNA
virus
B. It’s caused by a single stranded linear DNA
virus
C. It’s caused by a single stranded circular RNA
virus
D. It’s caused by a single stranded circular DNA
virus

• Correct answer: A
• This patient has adult t-cell leukemia-
lymphoma caused by HTLV
• Recent travel to the Caribbean
• A rash
• Hypercalcemia
• Lytic bone lesions
• Abnormalities of signaling pathways
that are classically associated with
cancer including the JAK-STAT pathway
and TP53
• HTLV is a single stranded linear RNA
virus
• B is incorrect because the only single
stranded DNA virus is Parvovirus B19 and
this is typically associated with aplastic
crises in sickle cell disease
• C is describing the RNA structure of
Bunyaviruses which are not associated with
adult T-cell leukemia-lymphoma
• D is a red herring because there isn’t a
single stranded circular DNA virus (DNA
viruses are all double stranded except
Parvovirus B19 and the DNA viruses that are
circular are also double stranded)
294
Section 16 - Hepatitis C Virus (HCV)
1. “C” shaped crop circle: Hepatitis C
2. Warm color scheme: RNA virus
3. Rainbow: positive sense
4. Icosahedral lights on spaceship: icosahedral capsid
5. Cow with liver spot stuck in tree branches: chronic
infection leads to liver cirrhosis
6. Pink cancer ribbon: cirrhosis can progress to
hepatocellular carcinoma
7. Bird’s nest on long branch: long incubation period
8. Alien with yellow skin: causes jaundice
9. Line in grass: linear virus
10. Man carrying oil lamp: causes fever
11. IV drip: transmission through IV drug use
12. Fat cow with bloody liver spot: liver biopsy
13. Harpoon pulling out white fur and yellow fat:
steatosis and lymphoid aggregates seen on liver
biopsy
14. “No cow tipping from 3-5” sign: lack of 3-5’
exonuclease activity, high antigenic variation, weak
immune response and no vaccine
15. Cow carrying the alien away from the fire:
asymptomatic carriers are possible
16. Dead cow with exposed ribs: treat with Ribavirin
17. Old sofa: treat with sofosbuvir
18. Man eating lead paint: treat with ledipasvir
19. Burn marks on alien: Hepatitis C infection is
associated with porphyria cutanea tarda
20. NHL no T.V.: Hepatitis C infections are associated
with non-hodgkin lymphoma (NHL)
21. Antibody-shaped antennas: Hepatitis C is associated
with cryoglobulinemia (antibodies clogging small
vessels)
22. Crying girl: Hepatitis C associated with antibodies
clogging small vessels (cryoglobulinemia)
23. Red balloons popped by antenna: Hepatitis C is
associated with autoimmune hemolytic anemia
(AIHA)
24. Rain gutter damage from antibody-shaped
antennas: Hepatitis C is associated with
membranous glomerulonephropathy
25. Splotchy red paint: Hepatitis C is associated with
lichen planus
26. Dyed beads hanging from wind chime: Hepatitis C is
associated with diabetes
27. Boy with antibody-shaped antenna smashing
neck: Hepatitis C is associated with autoimmune
hemolytic anemia
 295

REVIEW QUESTIONS ?
1. A 35-year-old man presents to clinic due to
complaints of fever and yellowing of his skin.
He has a 16-year history of IV drug abuse and
regular unprotected sex with prostitutes. The
physician orders blood tests which suggest
an active viral infection. Additionally, AST and
ALT levels were slightly elevated. Physical
Photo Credit: BruceBlaus (Adert traduzione) [CC BY-SA 4.0 (https:// examination reveals slight yellowing of the
creativecommons.org/licenses/by-sa/4.0)], adjustments made
sclera in both eyes. To treat the infection, the
physician prescribes ribavirin and ledipasvir.
Based on the likely virus, which of the following
statements is true?
A. The virus was most likely obtained through
unprotected intercourse
B. This infection confers a higher likelihood of
developing lichen planus
C. There is no vaccine because the virus lacks
an envelope
D. The liver is likely unaffected at this stage in
the patient’s illness
Photo Credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/
by-sa/3.0)] E. The virus could only have been transmitted
Figure 5.4.83 - Fat and lymphoid aggregates seen from a symptomatic carrier
• Correct answer: B
on HCV liver biopsy
• The patient likely has HCV based on the
following:
• Fever, jaundice, and scleral icterus
• Elevated AST and ALT
• History of IVDU
• Treatment with ribavirin and
ledipasvir
• HCV is associated with lichen planus
• Choice A is incorrect because HCV is more
likely to be transmitted through IVDU
• Choice C is incorrect because HCV is
Photo Credit: (left) by emmanuelsegmen via Flickr (alterations made); (right)
Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)] enveloped and vaccines are unavailable
because of the high rate of antigenic
variation on the envelope
• Choice D is incorrect because elevated AST
and ALT indicate current liver inflammation
• Choice E is incorrect because asymptomatic
individuals can carry and transmit HCV

Photo Credit: (left) James Heilman, MD [CC BY-SA 3.0 (https://

creativecommons.org/licenses/by-sa/3.0)]; (right) Masryyy [CC BY-SA 4.0
(https://creativecommons.org/licenses/by-sa/4.0)]
Figure 5.4.84 - Lichen planus
296
Section 17 - Yellow fever
1. Rainbow: positive sense
2. Man wearing all yellow: yellow fever
3. Yellow clothes: jaundice
4. Sweat: sweating and malaise
5. Bars trapping chimp: linear virus
6. Cane with icosahedral gem: icosahedral capsid
7. Needle and “Live monkey” sign: prevent with live
vaccine
8. Mosquitos in lake: transmitted through Aedes
mosquito
9. “Arbol” sign on tree: arbovirus
10. Human running towards monkey being bitten by
mosquitoes: humans and monkeys are reservoirs
11. Heat lamp: cause high fevers
12. Cow with liver spot: causes hepatitis
13. Cow running into person’s back: can cause back pain
14. Drinking water from lake with terrible flavor:
flavivirus
15. Vomiting: can cause black vomiting
16. Red color scheme: RNA virus
 297

REVIEW QUESTIONS ?
1. A 12-year-old girl is brought to the physician
due to “orange skin.” Her mother states that the
family recently returned from a trip to Brazil.
The patient denies receiving any vaccinations
prior to the trip. Her temperature is 39.4°C
(102.9°F). Physical examination confirms
jaundiced skin and tenderness of the right
upper quadrant of her abdomen. Blood results
indicate elevated AST and ALT. PCR is performed
and reveals the presence of an RNA arbovirus
with a linear genome. The physician reports
that the patient likely acquired a flavivirus
that is endemic to South America and Africa.
Which of the following is not true regarding the
presumed illness?
A. The Infection may have been prevented
with a live vaccine prior to travel
B. The virus does not carry its own RNA
polymerase
C. Mosquito repellant and long clothing may
have prevented infection
D. The virus has ribonucleotides in an
icosahedral configuration

• Correct answer: D
• The patient likely has yellow fever based
on the following:
• Jaundice and RUQ pain
• Elevated transaminases
• Viral PCR indicating an RNA
arbovirus with a linear genome
• Suspicion of a flavivirus endemic to
South America and Africa
• The capsid has an icosahedral
configuration, not the RNA genome
• Choices A, B and C are all true statements,
making them incorrect choices
298

Section 18 - Dengue Fever

1. Dinghy: Dengue fever 10. Water cooler: supportive care as treatment

2. Rainbow: positive sense
3. Warm colors: RNA virus
4. “Arbol” tree: arbovirus
5. Colony of mosquito larvae: obtained through
mosquito bites
6. Scuba diver with arm pain: myalgia
7. Heat lamp: fever
8. Rust on boat: rash
9. Icosahedral-shaped self propulsion device:
icosahedral capsid
11. Scuba diver with back pain: severe back pain
12. Line of bubbles: linear virus
13. Explosion above water: re-infection with different
serotypes is devastating
14. Electric explosion: shock
15. Blood in water: dengue hemorrhagic fever
16. Broken plates: low platelets
 299

REVIEW QUESTIONS ?
1. A 24-year-old man comes to his family physician
with severe back pain, a rash, and muscle
aches. Upon further history, the patient says
he recently returned from a humanitarian trip
to the Bahamas. He states that he has never
been there before and he received numerous
mosquito bites throughout the trip. His wife
said he likely has “breakbone fever”. If this is
correct, which of the following is true regarding
his condition?
A. He is infected with an arthropod-borne
parasite
B. If re-infected with a different serotype, his
presentation could be worse
C. The infectious organism is naked and
icosahedral
D. He may have diffuse hemorrhage prior to
illness resolution

• Correct answer: B
• The patient likely has Dengue fever
based on the following:
• Severe back pain, rash, and muscle
aches
• Mosquito bites
• If a patient acquires Dengue fever
a second time, and the serotype is
different, they can present with diffuse
hemorrhage
• Choice A is incorrect because Dengue fever
virus is a virus, not a parasite
• Choice C is incorrect because Dengue fever
virus is enveloped
• Choice D is incorrect because the first
Dengue fever infection is unlikely to cause
diffuse hemorrhage
300
Section 19 - West Nile Virus and St. Louis Encephalitis
1. “Breaking News: West Nile and St. Louis Encephalitis
Ravage North America” sign: St. Louis encephalitis
and West Nile Virus
2. Warm color scheme: RNA virus
3. St. Louis arch and west nile with swarms of
mosquitoes: both viruses are very similar
4. Rainbow: positive sense viruses
5. Microphone with icosahedral shape: icosahedral
capsid
6. Mosquitos in news studio: transmitted via mosquito
bites (arbovirus)
7. Fainting news anchor with water on head: can cause
encephalitis
8. Line of mosquitos on news anchor’s back: linear
virus
9. Worker spraying DEET mosquito repellent: prevent
with DEET (diethyltoluamide)
10. Long sleeve shirts: prevent with long sleeved
clothing
11. Gagging on bad flavored chemicals: flavivirus
 301

REVIEW QUESTIONS ?
1. A 52-year-old man is brought to the emergency
department by his wife due to confusion,
headaches and worsening weakness for 2
days. The wife explains that they have spent a
lot of time outdoors this summer to get some
sunshine. When asked about the situation,
the patient fails to respond appropriately.
On physical exam his temperature is 38.8°C
(102°F) and he demonstrates 2/5 strength of
the left upper extremity and 5/5 strength in all
other extremities. There are various bumps on
both arms, consistent with recent mosquito
bites. The physician is concerned about a viral
CNS infection and orders a lumbar puncture.
Cerebrospinal fluid is collected and results
are pending. Which of the following is most
consistent with the patient’s presentation?
A. The infection may have been prevented
with insect repellent
B. The pathogen is a linear virus with a helical
capsid
C. The virus can be transmitted via saliva from
an infected human
D. The virus is a member of the Picornaviridae
family

• Correct answer: A
• The patient likely has viral encephalitis
based on the following:
• Confusion, headaches, weakness
• Asymmetric muscle weakness
• Evidence of mosquito bites
• Concern for a “viral CNS infection”
• West Nile and St. Louis Encephalitis
are transmitted by mosquitoes which
means insect repellent can prevent
infection
• Choice B is incorrect because West Nile and
St. Louis Encephalitis are icosahedral
• Choice C is incorrect because human saliva
does not transmit West Nile and St. Louis
Encephalitis
• Choice D is incorrect because West Nile and
St. Louis Encephalitis are in the Flavivirus
family
302
Section 20 - Zika Virus
1. Giant mosquitos: mosquito-borne (arbovirus)
2. “Meet TanZIKA” sign: Zika virus
3. Line of tourists: linear virus
4. Warm colors: RNA virus
5. Rainbow: positive sense
6. Torches: transplacental infection (TORCHZ)
7. Penguin toy: congenital microcephaly
8. Heat lamp: fever
9. Icosahedral-shaped lamps: icosahedral capsid
10. Little boy with rash: rash
11. Bloody bucket full of mosquitos and chains hanging
from bucket: diagnose via serology or PCR
12. Red eyes: viral conjunctivitis
13. Water bottles: treat with supportive care
14. Gagging on water with bad flavor: Flavivirus
 303

REVIEW QUESTIONS ?
1. A 23-year-old female at 9 weeks gestation
presents with a low-grade fever and red eyes
after returning from a vacation in Tahiti. She
learned of a recent outbreak of Zika virus at her
vacation destination and is now worried about
what a Zika infection could do to her baby. What
congenital malformation is associated with
transplacental Zika infection?

• Correct answer: Fetal microcephaly is a

known complication of Zika infections in
pregnant women
304
Section 21 - Rubella
1. Red bell: Rubella
2. German Shepherd dog: previously known as
“German Measles”
3. Toga: a member of the togavirus family
4. Warm colors: RNA virus
5. Rainbow: positive sense virus
6. Line of people waiting for fight: linear
7. Icosahedral shaped bell: icosahedral
8. Mist: transmitted via aerosolized respiratory
droplets
9. Injured gladiator covered in blood: causes a
maculopapular rash that starts on the face and
spreads to the trunk and extremities
10. Curly hair behind ears: causes posterior
lymphadenopathy
11. Injured swordsman holding leg: causes arthralgias
12. Torch: TORCHES infection
13. Mother wearing eye patch: congenital rubella may
cause cataracts
14. Mother wearing ear muffs: congenital rubella may
cause deafness
15. Mother eating blueberry muffin: congenital rubella
may cause a “blueberry muffin” rash
16. Cart with “PDA” near couple showing PDA:
congenital rubella may cause a patent ductus
arteriosus
17. Yellow paint near mother: congenital rubella may
cause jaundice
18. “Live show” sign shaped like a syringe: live vaccine
available
 305

REVIEW QUESTIONS ?
1. A newborn male is born at 38 weeks’ gestation
to a 27-year-old unvaccinated woman. He has
purple purpuric skin lesions and a continuous
murmur best heard over the left infraclavicular
area. During the first trimester the mother had
an illness caused by a single-stranded, positive-
sense, RNA virus with an envelope. Which of the
following clinical features did the mother most
likely experience during this time?
A. A mononucleosis-like illness
B. Vesicular genital lesions
C. A maculopapular rash
D. A painless genital ulcer

• Correct answer: C
• The infant is presenting with a “blueberry
muffin” rash caused by congenital rubella
• Purple purpuric skin lesions →
“blueberry muffin” rash
• Continuous murmur best heard over the
left infraclavicular area → patent ductus
arteriosus
• The mother developed an illness during
the first trimester which was caused by
a single-stranded, positive-sense, RNA
Photo Credit: CDC [Public domain] virus with an envelope
Figure 5.4.85 - Maculopapular rash of Rubella • Rubella causes a maculopapular rash
that starts on the face and spreads to
the trunk and extremities
• So the mother most likely developed a
rash during her first trimester but may
have also developed posterior auricular
lymphadenopathy or arthralgias
• A is a reference to CMV which can also
cause a “blueberry muffin” rash but is not
an RNA virus
• B is a reference to HSV which can cause
recurrent infections and chronic diarrhea in
a neonate - not a “blueberry muffin” rash
and a PDA
• D is a reference to syphilis but this is a
bacterium and is not associated with a PDA
or a “blueberry muffin” rash
306
Section 22 - Eastern, Western, and Venezuelan equine encephalitis viruses; Chikungunya
virus
1. Toga: Togaviridae
2. East, West, and South sign: Eastern, Western, and
Venezuelan equine encephalitis
3. Cat in tree eating chicken: Chikungunya virus
4. Warm colors: RNA virus
5. Rainbow: positive sense
6. Icosahedral-shaped souvenir: icosahedral
7. Mosquito swamp: transmitted by mosquitoes
8. “Arbol” tree: arboviruses
9. Red knee on cat in tree: Chikungunya virus can
cause joint pain
10. Black spots on fur of cat: Chikungunya virus can
cause a rash
11. Sweating cat: Chikungunya virus can cause flu-like
symptoms
12. Characters throwing water on top of each other’s
heads: Eastern, Western, and Venezuelan equine
encephalitis viruses can cause encephalitis
 307

Photo Credit: Nsaa [CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)]

Figure 5.4.86 - Chikungunya-related erythematous maculopapular rash

REVIEW QUESTIONS ?
1. A 25-year-old male presents to his doctor due • Correct answer: A
to a rash on his hands that he noticed yesterday. • This patient has an infection caused by
He states that 3 days ago he returned home Chikungunya virus
from a trip to West Africa and hasn’t been • A rash
feeling well since. His temperature is 39.9°C • Fever
(103.8°F). Physical examination reveals a • Due to a togavirus
maculopapular rash on the patient’s hands and • Chikungunya virus is transmitted by the
arms. Additional evaluation reveals that the Aedes mosquito
causal organism is a togavirus. This patient’s • B is a reference to several organisms such
condition is most likely transmitted by which of as Borrelia burgdorferi, Babesia, and
the following? Anplasma but none of these are togaviruses
• C and D are true of many pathogens but not
A. The Aedes mosquito
of togaviruses (togaviruses are transmitted
B. The Ixodes deer tick
C. Sexual contact by the Aedes mosquito)
D. Aerosolized water droplets
308
Section 23 - California Encephalitis
1. “Welcome to California” sign on Golden Gate
Bridge: California encephalitis
2. Red colors: RNA virus
3. Hot dog buns: a member of the Bunyavirus family
4. Rain clouds: negative sense
5. Helical shaped wires on bridge: helical capsid
6. Little girl drawing circles: circular
7. Little boy with chocolate bar: 3 segments
8. “Arbol” tree: arbovirus
9. Mosquito in car: transmitted through mosquitoes
10. Map of the United States with central and east coast
highlighted: common in the central and eastern part
of the U.S.
11. Boy sticking head out of window into rain: causes
encephalitis
 309

REVIEW QUESTIONS
1. A 9-year-old girl is brought to the emergency
department due to altered mental status. Her
father states that yesterday she complained of
a headache and then vomited several times.
However, this morning she was disoriented to
time and place. During the interview the patient
begins to seize. After appropriate management,
analysis of the CSF reveals an RNA virus with
a single stranded circular genome that has 3
segments. What is the most likely diagnosis?
A. Lymphocytic choriomeningitis virus
B. California encephalitis
C. St. Louis encephalitis
D. West Nile virus
?
• Correct answer: B
• This girl has encephalitis caused by
California encephalitis
• Altered mental status
• Headache
• Vomiting
• A virus that was found in the CSF
• The pathogen is an RNA virus with a
single stranded circular genome that has
3 segments → Bunyavirus
• A, C, and D can all cause neurological
deficits but only California encephalitis has
a circular genome with 3 segments
310
Section 24 - Rift Valley Fever and Crimean-Congo Hemorrhagic Fever Virus
1. “WELCOME TO THE CONGO” sign: Crimean-Congo
hemorrhagic fever
2. “WELCOME TO THE VALLEY” sign: Rift Valley fever
virus
3. Hotdog bun: Bunyavirus
4. Warm colors: RNA virus
5. Dark rain cloud: negative sense virus
6. Circular-shaped greenery: circular
7. 3 segmented chocolate bar: 3 segments
8. Helical shaped chain: helical capsid
9. “Arbol” tree: arbovirus
10. Traveler in the valley getting attacked by mosquitos:
Rift Valley fever virus is transmitted by mosquitoes
11. Man in boat eating tic tacs: Crimean-Congo
hemorrhagic fever is transmitted by ticks
12. Red river: Crimean-Congo hemorrhagic fever causes
hemorrhagic fever
13. Lamp: Rift Valley fever virus and Crimean-Congo
hemorrhagic fever can cause fever
14. Headbands: Rift Valley Fever virus and Crimean-
Congo hemorrhagic fever can cause neurological
disturbances
15. Map of Africa: prevalent in Africa

REVIEW QUESTIONS
1. A 24-year-old male presents to the emergency
department due to vision changes and a rash
that he noticed yesterday. He recently returned
home from a humanitarian trip to Nigeria.
His temperature is 39.7°C (103.4°F). Physical
examination reveals a petechial rash on his
arms and legs. Fundoscopy reveals retinal
hemorrhage. Further evaluation reveals that the
pathogen is a single-stranded, negative-sense
virus that is comprised of 3 RNA segments. This
patient’s condition was most likely transmitted
through which of the following?
A. Rodents
B. Mosquitoes
C. Ticks
D. Aerosolized respiratory droplets
E. Dogs   transmitted by ticks
311
?
• Correct answer: C
• This patient has Crimean-Congo
hemorrhagic fever
• Recent travel history to Nigeria, fever,
petechial rash, and retinal hemorrhages
• Single-stranded, negative-sense, 3
segments → Bunyavirus
• Crimean-Congo hemorrhagic fever and
Hantavirus are bunyaviruses and can
cause the patient’s symptoms but the
travel history makes Crimean-Congo
more likely
• Crimean-Congo hemorrhagic fever →
Africa
• Hantavirus → China
• Crimean-Congo hemorrhagic fever is
• A is incorrect because it refers to the route
of transmission of Hantavirus
• B is incorrect because while it is true that
many viruses (including some Bunyaviruses)
are transmitted by mosquitoes, they do not
present with hemorrhagic fever
• D is incorrect because Bunyaviruses are not
transmitted through aerosolized respiratory
droplets
• E is incorrect because it is a reference to
bacteria (Campylobacter jejuni and Yersinia
enterocolitica) but these do not cause
hemorrhagic fever
312

Section 25 - Hantavirus

1. Haunted house: hantavirus 8. Shirt with China graphic: prevalent in China

2. Red colors: RNA virus
3. Rain clouds: negative sense
4. Spiral staircase: helical capsid
5. Circular shaped entrance: circular
6. Girl eating chocolate bar: 3 segments
7. Girl with hot dog bun: Bunyavirus
9. Man in rodent costume: transmitted through
rodents
10. Bloody teeth, holding lamp: causes hemorrhagic
fever
11. Axe shaped like lungs: causes pulmonary disease
 313

REVIEW QUESTIONS ?
1. A 36-year-old male presents to the physician
due to shortness of breath. He states that his
shortness of breath began earlier today, but
approximately one week ago he developed a
fever, chills, and myalgias. He also mentions
that he recently returned home from a trip to
China where he lived in a house infested with
rodents. This patient’s condition is most likely
due to a virus that has which of the following
characteristics?
A. RNA, 3 segments, circular
B. RNA, 2 segments, circular
C. RNA, 10-12 segments, linear
D. RNA, 8 segments, linear

• Correct answer: A
• This patient has a Hantavirus infection
• Shortness of breath
• Recent trip to China
• Exposure to rodent-infested house
• Hantavirus is a circular RNA virus with 3
segments
• B is false because it is referring to Lassa
fever encephalitis which is also spread by
rodents but presents with encephalitis and
not pulmonary symptoms
• C is false because it is referring to
Reoviruses which cause GI symptoms and
are not associated with rodent exposure
• D is false because it is referring to the
Influenza virus which also has pulmonary
symptoms but the travel history and rodent
exposure make Hantavirus more likely
314
Section 26 - Influenza virus
1. Flute: influenza
2. Orthodontist sign: orthomyxovirus
3. Warm colors: RNA virus
4. Rain cloud: negative sense
5. Line of people at concert: linear virus
6. Car with v8 engine: 8 segments
7. Spiral staircase: helical capsid
8. Fish tank with nuclear sign: replication in the
nucleus of the host cell
9. “He needs in” near entrance: hemagglutinin is a
surface glycoprotein that facilitates viral entry into
the host cell
10. Antibody-shaped door knocker: antibodies against
hemagglutinin provide future immunity to similar
strains of influenza
11. Pack of new erasers near exit: neuraminidase is an
enzyme associated with the release of viral progeny
from the host cell
12. Hot tamales: zanamivir and oseltamivir (Tamiflu)
can be used to treat influenza by disrupting
neuraminidase
13. Letters drifting in the air: exhibits genetic drift
(random mutations that occur in the hemagglutinin
and neuraminidase gene)
14. Gear shift handle, assorted chocolate box, and pet
animal: exhibits genetic shift (two distinct strains
undergo genetic reassortment resulting in a novel
strain)
15. Skull shirt: genetic shift is more deadly than genetic
drift
16. Heat lamps: may cause fever
17. Fan holding arm in pain: may cause myalgias
18. Fan coughing up soda: may cause a cough
19. Smoke from broken down car: may cause primary
pneumonia
20. “The office” bumper sticker, Merlin tattoo, and
lawn mower tattoo: May cause secondary bacterial
pneumonia (most often due to Staphylococcus
aureus, Streptococcus pneumoniae, and
Haemophilus influenzae)
21. Car: may cause cardiac complications
22. Hats: may cause neurological complications (aseptic
meningitis)
23. Ray of light: associated with Reye syndrome
24. Orthodontist with syringe: killed vaccine
25. “Live show” syringe with guy smelling scented
flowers: live vaccine (replicates in nose but not
lungs)

Figure 5.4.87 - Genetic shift and genetic drift
REVIEW QUESTIONS
1. A 64-year-old male presents to the physician
due to a fever, cough, and shortness of breath
that began yesterday. He states that he also had
similar symptoms a week ago. His symptoms
began to improve up until yesterday when
they suddenly became worse. His temperature
is 38.9°C (102.0°F). Pulmonary auscultation
reveals crackles in the lower lobes bilaterally.
A sputum culture will most likely grow an
organism with which of the following features?
A. Pyocyanin production
B. Growth on charcoal yeast extract
C. Decreased muramic acid in the cell wall
D. Colonization of the nares
315
?
• Correct answer: D
• This patient has secondary bacterial
pneumonia following an infection by
Influenza virus
• Fever, cough, shortness of breath,
crackles in lower lobes of the lungs →
pneumonia
• Secondary bacterial pneumonia is
commonly caused by Staphylococcus
aureus
• Staphylococcus aureus colonizes the
nares
• A-C are references to bacterial species that
cause pneumonia but are not as commonly
associated with secondary bacterial
pneumonia
• A is a reference to Pseudomonas aeruginosa
• B is a reference to Legionella pneumophila
• C is a reference to Chlamydia trachomatis
316
Section 27 - Lassa fever encephalitis and Lymphocytic choriomeningitis virus
1. Baseball arena: Arenavirus
2. Warm colors: RNA virus
3. Two circular mounds: two segments and a circular
structure
4. Rainbow and clouds: positive sense and negative
sense
5. Spiral staircase: helical capsid
6. Limping umpire with unique helmet: lymphocytic
choriomeningitis virus
REVIEW QUESTIONS
1. A 24-year-old female is brought to the
emergency department due to altered mental
status over the past 24 hours. Her boyfriend
accompanies her and states that many of their
recent conversations have been nonsensical.
Her temperature is 38.6°C. PCR analysis of the
CSF reveals a virus with a linear double stranded
DNA structure. Based on these findings, what is
the most likely diagnosis?
A. Lassa fever encephalitis
B. Lymphocytic choriomeningitis virus
C. Herpes simplex virus-1
D. JC virus
7. Water on top of umpire helmet: causes
meningoencephalitis
8. Lassie dog with rain over head: Lassa fever
encephalitis
9. Rodents: spreads by rodents
10. Ghanaian person: prevalent in West Africa
?
• Correct answer: C
• This patient has encephalitis caused by HSV-
1
• Altered mental status and fever →
encephalitis
• PCR reveals a linear double stranded
DNA virus → HSV-1
• A and B are incorrect because they are
arenaviruses which are RNA viruses
• D is incorrect because JC virus has a circular,
double-stranded DNA structure

Section 28 - Hepatitis D Virus
1. Dogs herding cows with liver spots: hepatitis D virus
2. Delta airplane: belongs to deltavirus family
3. Warm colors: RNA virus
4. Dark clouds: negative sense
5. Circular lasso: circular
6. Pregnant woman with “S” on shirt: sexually and
perinatally transmitted
317
7. Beehive: HDV is dependent on HBV to cause
infection
8. People running away from bees and taking off their
coats near dogs: must be coated with the surface
antigen of HBV to cause infection
9. Cow stuck in dead weeds: increases risk of cirrhosis
10. Shattered glass on ground: a liver biopsy will show
“ground glass” hepatocytes
318

 
Figure 5.4.88 - Acute HDV-HBV coinfection
 

Figure 5.4.89 - HDV superinfection


REVIEW QUESTIONS
1. A 33-year-old male presents to the physician
due to 3 days of right upper quadrant
abdominal pain, a subjective fever, and
jaundice. He has been with multiple male
partners over the past several years and is
worried he has HIV. Serological markers are
drawn and reveal the following:
Hepatitis B surface antigen positive
IgG hepatitis B core antibody positive
Hepatitis D RNA positive
HIV-1 antibody negative
This patient’s acute condition is most likely caused
by a virus with which of the following features?
A. A partially double-stranded, circular DNA
virus
B. A single-stranded, negative-sense, circular
RNA virus
C. A single-stranded, positive-sense, linear
RNA virus
D. 2 copies of a single-stranded, positive-
sense, linear RNA virus
319
?
• Correct answer: B
• This patient has an HDV superinfection
• 3 days of right upper quadrant
abdominal pain, subjective fever,
jaundice → acute hepatitis
• The patient’s sexual history makes HBV,
HDV, and HCV possible  
• IgG hepatitis B core antibody test →
chronic HBV infection present
• Hepatitis D RNA →  acute HDV
superinfection
• HDV is a single-stranded, negative-
sense, circular RNA virus
• A is true of HBV but the patient’s acute
condition is due to an HDV superinfection
• C is true of HAV which is not sexually
transmitted and would not include the lab
findings present in this patient
• D is true of HIV but the HIV-1 antibody test
was negative
320
Section 29 - Parainfluenza Virus
1. Warm colors: RNA virus
2. Dark clouds on newspaper: negative sense
3. Pair of crayons mixing and melting: paramyxovirus
4. Pair of flutes: parainfluenza virus
5. Helical-shaped slinky: helical capsid
6. Dog sniffing line of footprints: linear virus
7. Crayon trying to catch his breath: respiratory
distress
8. Barking dog: barking cough
9. Collar choking trachea of dog: tracheal narrowing
10. Crayon drawing of church: steeple sign
11. Stripes on church: stridor
12. Crayon poop: croup
13. Dog sneezing: upper respiratory symptoms
14. “He needs in”: hemagglutinin permits viral entry by
binding to sialic acid
15. Crayons with new erasers: neuraminidase
16. Dog pulling pair of boxes: can cause pulsus
paradoxus
 321

REVIEW QUESTIONS ?
1. A 2-year-old boy is brought to the pediatrician
due to strange noises each time he coughs.
The boy’s mother says that he sounds like
a coughing seal. On physical examination
he appears mildly uncomfortable and
demonstrates rib retractions. The physician
informs the mother that her son has croup.
Which of the following is true regarding this
patient’s condition?
A. He has been infected with an influenza virus
B. A radiograph may reveal subglottic
narrowing
C. The virus is ready to be translated upon
entry to the host cell
D. The virus has double stranded genetic
material
Photo Credit: Frank Gaillard [CC BY-SA 3.0 (https://creativecommons.
org/licenses/by-sa/3.0)]
• Correct answer: B
Figure 5.4.90 - Steeple sign on radiograph in croup • The patient likely has croup based on
the following:
• Seal-like cough
• Rib retractions
• Croup can cause subglottic narrowing
when radiographed
• Choice A is incorrect because parainfluenza
virus is a type of paramyxovirus
• Choice C is incorrect because parainfluenza
virus is a negative-sense RNA virus and must
first be converted to a positive sense strand
using its RNA-dependent RNA polymerase
• Choice D is incorrect because parainfluenza
virus is single-stranded
322
Section 30 - RSV and hMPV
1. Red Searing Vent: RSV
2. Pair of melted crayons mixing: paramyxovirus
3. Human metal toy: human metapneumovirus
(HMPV)
4. Line of cars: linear virus
5. Warm colors: RNA virus
6. Helical slinky toy: helical capsid
7. Retracting ribs on baby: respiratory distress in
infants
8. Sweating mom: fever
9. Dark clouds: negative sense
10. Dark clouds carry moisture: negative sense RNA
viruses carry their own RNA polymerase
11. Boy wiping mucus on seat: mucus, drainage, and
congestion
12. Balloon letting out air: wheezing
13. Cracks in sidewalk shaped like lungs: bronchiolitis
14. Pallet of visine: palivizumab
15. Water jug: supportive care
16. Oxygen mask: treat with respiratory support and
oxygen supplementation
 323

REVIEW QUESTIONS ?
1. A 2-week-old female is brought to the
pediatrician by her mother due to persistent
nasal drainage and a worsening cough. The
mother states the infant has “felt warm” but has
not taken the patient’s temperature. On physical
exam, the physician notices nasal flaring,
subcostal retractions, and respiratory crackles
on chest auscultation. The physician suspects
bronchial inflammation due to a negative sense
RNA virus. Assuming the physician is correct,
what should be the recommended treatment?

• Correct answer: provide supportive care,

including fluid and respiratory support
• The patient likely has an RSV or hMPV
Photo Credit: Matteo Di Nardo, Daniela Perrotta, Francesca Stoppa, infection based on the following:
Corrado Cecchetti, Marco Marano and Nicola Pirozzi [CC BY 2.0
(https://creativecommons.org/licenses/by/2.0)], via Wikimedia • Negative sense RNA virus
Commons • Bronchial inflammation
Figure 5.4.91 - Bronchiolitis on chest radiograph (bronchiolitis)
• Subcostal retractions and nasal
flaring (respiratory distress)
324

Section 31 - Measles

1. Weasels: measles 11. Weasel licking gum spot: can cause Koplik spots
2. Warm colors: RNA virus 12. Pair of melting and mixing crayons: paramyxovirus
3. Dark clouds: negative sense 13. Red skull: subacute sclerosing panencephalitis
4. Retail store: retinol 14. Red-eyed weasel: coryza and conjunctivitis
5. “Live weasels inside” sign shaped like a syringe: live 15. Helical-shaped slinky: helical capsid
vaccine prevents measles 16. Netted cage with white toy balls melting together:
6. Line of fire: linear virus fused lymphocytes (Warthin-Finkeldey) and
7. Coughing weasel: causes cough hyperplasia in lymph nodes
8. Oil lamp: fever 17. Giant explosion near man on stretcher: giant cell
9. Red ash landing on face and traveling down: pneumonia in immunocompromised patients
maculopapular rash spreads downwards 18. Weasels with cough, conjunctivitis, coryza, koplik
10. Water pouring over weasel’s head: can cause spots, and rash: uncomplicated measles
encephalitis
 325

REVIEW QUESTIONS ?
1. An unvaccinated 2-year-old girl presents with
a cough and watery eyes. A serum lab test
confirms high levels of measles IgM. After
further discussion with the girl’s mother, the
clinician suspects the child is malnourished and
likely has a deficiency of retinol. Which of the
following symptoms is most likely to present
next?
A. Encephalitis
B. Giant cell pneumonia
C. Maculopapular rash
D. Watery diarrhea
Photo Credit: Wikimedia Commons [Public domain]
Figure 5.4.92 - Maculopapular rash in measles • Correct answer: C
• The patient likely has uncomplicated
measles based on the following:
• Cough
• Watery eyes (coryza)
• Measles IgM
• Choice A is incorrect because complicated
pneumonia with encephalitis is less likely
than a maculopapular rash, even though the
patient is deficient in vitamin A (retinol)
• Choice B is incorrect because the patient is
not immunocompromised
• Choice D is incorrect because diarrhea is not
associated with measles
Photo Credit: CDC [Public domain], via Wikimedia Commons
Figure 5.4.93 - Koplik’s spots

Photo Credit: Content Provider(s): CDC/Dr. Edwin P. Ewing, Jr. [Public

domain], via Wikimedia Commons
Figure 5.4.94 - Giant cells
326

Section 32 - Mumps

1. Warm color scheme: RNA virus
2. Bumps of crayons: mumps
3. Dark and negative rain clouds: negative sense
4. Flaming pan: pancreatitis
5. Pair of mixing crayons: paramyxovirus
6. Crayon line: linear virus
7. Big cat cheeks: parotitis
8. Pot dropping on head of kid with hat: meningitis
9. Ball of crayons: Orchitis
10. Stepping on testicle-shaped crayon mounds: sterility
11. “Vaccine free!!” hoodie: unvaccinated children at
risk
12. “Live: Mumps outbreak”: live vaccine (MMR)
 327

REVIEW QUESTIONS ?
1. A 35-year-old male presents to his family
physician complaining that he and his wife have
been unable to conceive despite trying for 5
years. He believes he may be infertile. Upon
further questioning, he describes having swollen
testicles when he was a kid during a “weird”
illness. The physician suggests the patient’s
described illness is likely the source of his
infertility. Which of the following is most likely
true regarding this patient’s childhood illness?
A. It was caused by an orthomyxovirus
B. He was fully immunized at the time
C. He may have also had parotid gland
inflammation
Afrodriguezg [CC BY-SA 3.0 (https://creativecommons.org/ D. The infectious agent did not carry its own
licenses/by-sa/3.0)], from Wikimedia Commons RNA polymerase
Figure 5.4.95 - Mumps-related parotitis
• Correct answer: C
• The patient likely had mumps as a child
based on the following:
• Swollen testicles
• Fertility issues
• Mumps is known to cause parotid gland
inflammation (parotitis)
• Choice A is incorrect because Mumps is a
paramyxovirus, not an orthomyxovirus
• Choice B is incorrect because Mumps is
prevented through vaccination
• Choice D is incorrect because Mumps is a
negative sense virus and must carry its own
RNA-dependent RNA polymerase into host
cells
328
Section 33 - Rabies Virus
1. Infected beast: Rabies
2. Warm color: RNA virus
3. Negative rain clouds: negative sense
4. Foaming at the mouth: patients experience
hypersalivation
5. Holding head: can cause headaches
6. Were-raccoon: raccoons are reservoirs
7. Bats: bats are reservoirs
8. Skunks: skunks are reservoirs
9. Game of memory: rabies infects the hippocampus
10. Dead beast: rabies ultimately causes death
11. Bullet shells: bullet-shaped envelope
12. Wounds: Negri bodies are cytoplasmic inclusions
found in neurons
13. Man losing balance on bell tower: Rabies infects the
cerebellum
14. Bungee cord: rabies virus infects the Purkinje
neurons within the cerebellum
15. Rabid beast recoiling at water: rabies causes
hydrophobia
16. Water splashing on hat: causes encephalitis
17. The bell and game of memory: Rabies virus can be
found in the cerebellum and hippocampus
18. Beast devouring seagull: Rabies virus attacks
acetylcholine receptors
19. Dynamite: dynein motors carry Rabies virus up the
axon in a retrograde fashion
20. Lowest light burning out: Rabies travels up axon in a
retrograde fashion
21. Paralyzed leg: Rabies can cause sensation loss and
paralysis
22. Line the ground: Rabies is a linear virus
23. Curly tails: Rabies has a helical capsid
24. Sick-looking human: flu-like symptoms early in the
disease
25. Broken vaccine needles: treat patients with killed
vaccine
26. Clothes pins: treat acute infections with rabies
immunoglobulin
 329

Photo Credit: [Public domain]

Figure 5.4.96 - Rabies virus structure

Photo Credit: CDC, [Public domain] via Wikimedia Commons

Figure 5.4.97 - Rabies virus bullet-shaped envelopes
on electron microscopy

Photo Credit: CDC/Dr. Daniel P. Perl [Public domain]

Figure 5.4.98 - Rabies virus Negri bodies
330

Figure 5.4.99 - Retrograde movement of Rabies virus


REVIEW QUESTIONS
1. A 43-year-old male was bitten on the right
hand by a bat while cleaning out his cabin in
a forested area. Several months later he died
and an autopsy was performed. An electron
micrograph of the cerebellum was taken
following dissection of the patient’s brain which
is shown below. Which of the following is most
likely true regarding the deceased patient’s
condition?
A. The patient did not experience fever and
malaise early in the disease
B. He experienced numbness in his right hand
during his illness
C. Rabies immunoglobulin and live rabies
vaccine should have been administered
soon after the bite
D. The patient avoided water due to perceiving
a bitter taste
331
?
• Correct answer: B
• The patient likely has rabies based on
the following:
• Electron microscopy revealing
bullet-shaped envelopes
• Bat bite
• Biopsy taken from the cerebellum
• Rabies causes loss of sensation or motor
function in a retrograde fashion
• Choice A is incorrect because rabies causes
fever and malaise early in the infection
• Choice C is incorrect because infected
patients should receive a killed vaccine and
immunoglobulins
• Choice D is incorrect because painful
pharyngeal spasms cause hydrophobia
332

Section 34 - Ebola Virus and Marburg Virus

1. Marburg’s bowling alley: Marburg virus and Ebola
virus
2. Zombie files: filoviridae
3. Negative rain clouds: negative sense
4. Warm colors: RNA virus
5. Bleeding zombie: diffuse hemorrhage
6. Smeared line of blood: linear virus
7. Packs of coagulated Jello: diffuse intravascular
coagulation
8. Pulled muscle: myalgias
9. Shocked to death: shock
10. Heat lamps: fever
11. Sick-looking man: flu-like symptoms
12. Apes eating from dead body: spread via dead
bodies, fomites, and apes
13. Walking through bodily fluids: spreads via direct
contact with bodily fluids
14. Diarrhea and vomiting: diarrhea and vomiting
15. Healthcare worker: wear personal protective
equipment (PPE)
16. Water bottle: treat with supportive care
17. 3 chains: diagnose with polymerase chain reaction
(PCR)
 333

REVIEW QUESTIONS ?
1. A 35-year-old African-American female presents
to the emergency department due to concerns
that she is infected with the Ebola virus.
She recently traveled to Sierra Leone to visit
extended family and returned 1 week ago. Since
returning to the United States, she learned that
there was an outbreak of Ebola in the town she
visited. She now reports a fever, muscle aches
and several episodes of emesis over the past
24 hours. If she is infected with the Ebola virus,
which of the following is most likely true?
A. Antiviral medication may reduce the
duration of her illness
B. PCR will confirm the diagnosis
C. She had sexual contact with an infected
person
D. She should go home immediately and
minimize her contact with other people

• Correct answer: B
• Choice A is incorrect because antivirals are
unavailable to treat Ebola virus
• Choice C is incorrect because Ebola is not
sexually transmitted
• Choice D is incorrect because the patient
should be quarantined at the hospital, not
sent home
334

Section 35 - Norovirus

1. Chalice: Calicivirus 7. Poop on shoe: fecal-oral transmission

2. Nordic viking: Norovirus
3. Warm colors: RNA virus
4. Naked viking: naked
5. Rainbow: positive sense
6. Linear formation: linear
8. Icosahedral water jug: icosahedral
9. Seasick Vikings: vomiting and watery diarrhea
10. United States sail: common in developed countries
11. Water: treat with supportive care
 335

REVIEW QUESTIONS ?
1. A resident physician is in Nepal on a
humanitarian trip when a diarrheal outbreak is
reported at a nearby elementary school. Nine
children are brought to the clinic after several
days of intense vomiting and watery diarrhea.
No blood is detected in the stool. None of the
children are immunized. Which of the following
pathogens is most likely responsible for the
outbreak?
A. Norovirus
B. Adenovirus
C. Rotavirus
D. Shigella
 
• Correct answer: C
• This patient has a viral gastroenteritis
caused by Rotavirus
• Unvaccinated children
• Developing country
• Absence of blood in stool
• A is incorrect because Norovirus is more
common in developing countries among
unimmunized individuals
• B is incorrect because Adenovirus can cause
gastroenteritis but is a much less common
cause of diarrheal outbreaks (more
commonly associated with pharyngitis,
conjunctivitis, and coryza)
• D is incorrect because Shigella is a bacterial
cause of gastroenteritis and is much more
likely to result in a bloody diarrhea
336

Section 36 - Hepatitis E virus

1. Cow being eaten: Hepatitis E virus 6. First egg to hatch: short incubation period
2. Warm colors: RNA virus 7. Man stepped in poo: fecal-oral transmission
3. Rainbow: positive sense 8. Pregnant woman next to skull: fulminant hepatitis in
4. Naked man: naked virus pregnant women (high mortality rate)
5. Heap of eggs: Hepevirus 9. Black spots: liver biopsy shows patchy necrosis
 337

REVIEW QUESTIONS ?
1. A 29-year-old pregnant female presents to
the emergency department due to malaise,
nausea, vomiting, and abdominal pain. Physical
examination reveals diffuse jaundice and
hepatomegaly. Despite aggressive intervention,
she passes away several hours later. During an
autopsy, a pathological specimen of her liver
reveals ballooned hepatocytes and focal areas
of necrosis. The organism responsible for this
patient’s condition:
A. Is a DNA virus
B. Is transmitted parenterally
C. Is a positive sense virus
D. Is an enveloped virus
E. Causes hepatocellular carcinoma
 
• Correct answer: C
• The patient had a hepatitis E infection
resulting in death
• Pregnant female, jaundice, and
hepatomegaly
• Hepatitis E is a positive sense virus
• Causes fulminant hepatitis in pregnant
women
• A is incorrect because hepatitis E is an RNA
virus  
• B is incorrect because hepatitis E is
associated with fecal-oral transmission
• C is incorrect because parenteral
transmission refers to IV drug users and this
is more commonly associated with hepatitis
B, C, and D
• D is incorrect because hepatitis E is a naked
virus
• E is incorrect because hepatitis B and C are
associated with hepatocellular carcinoma
but hepatitis E is not
338
Section 37 - Rotavirus and Colorado Tick Fever
1. Rio Grande river: reoviruses
2. Colt gun: Coltivirus
3. “Welcome to Colorado” and heat lamp: Colorado
tick fever virus is a Coltivirus
4. Arbol: Colorado tick fever virus is an arbovirus
5. Tic tacs: transmitted through ticks
6. Rotary motion: Rotavirus
7. Warm colors: RNA virus
8. Two waterfalls: double stranded
9. Line of people: linear
10. “10-12 ways to Tube”: approximately 11 segments
11. Naked guy: naked
12. Icosahedral-shaped ice cream cone: Icosahedral
13. Wheel: wheel-like shape seen on electron
microscopy
14. Vomiting child: Rotavirus causes watery diarrhea
and vomiting (can be fatal in children)
15. Shaved ice and snow: Rotavirus is more common
during the winter time in the U.S.
16. Cacti: Rotavirus causes intestinal villi destruction
17. “Live animals” sign: live vaccine for Rotavirus
18. Skid marks and syringe: do not give vaccine to
patients with SCID
19. Telescopic lens: live vaccine increases the risk of
intussusception

Figure 5.4.100 - Positive-sense and negative-sense viruses
Photo Credit: Dr. Graham Deards [CC BY 3.0 (https://
creativecommons.org/licenses/by 3.0)]
Figure 5.4.101 - Transmission electron micrograph
of Rotavirus
REVIEW QUESTIONS
1. A 3-year-old unvaccinated male is brought
to the physician due to a temperature of
38.6°C (101.5°F), vomiting, and diarrhea. After
thorough evaluation, the patient’s condition
is thought to be due to a viral infection.
Laboratory analysis reveals that the virus is
double-stranded, RNA, and linear. Which of the
following is true regarding the most likely causal
organism?
A. It is enveloped
B. The capsid symmetry is helical
C. Electron microscopy of a stool sample will
reveal viral particles with a wheel-like shape
D. The nucleic acid is non-segmented
339
?
• Correct answer: C
• This patient has viral gastroenteritis caused
by Rotavirus
• Unvaccinated child with vomiting and
diarrhea
• The virus is double-stranded, RNA, and
linear
• Electron microscopy of a stool sample
of individuals with a rotavirus infection
will reveal viral particles with a wheel-
like shape
• A is false because reovirus is a naked virus
• B is false because the capsid symmetry is
icosahedral
• D is false because reoviruses have 10-12
segments
340
Section 38 - Poliovirus
1. Warm color: RNA virus
2. Rainbow: positive sense
3. Pole-vaulting guy: poliovirus
4. Asteroid breaking into pieces: one big protein is
cleaved into several smaller, functional proteins
5. Panda eating socks with needle in head: Salk vaccine
is killed
6. “Live saber tooth tiger” poker: Sabin vaccine is live
7. IRS henchman: contains internal ribosomal entry
site (IRES)
8. Naked henchman: naked virus
9. Naked henchman in mud river: naked viruses enter
host ell via endocytosis
10. Henchman at junction of brown and red river:
poliovirus enters the intestines and then the
bloodstream
11. Poles blocking entrance of central facility: poliovirus
enters the CNS
12. Hat knocked off henchman: causes meningitis
13. Grabbing ox horns: infects anterior horns of spinal
cord
14. Shaking ox: causes fasciculations
15. Limp ox: flaccid paralysis
16. Peacock emperor: picornavirus
17. Icosahedral gems on staff: icosahedral capsid
18. Wimpy and defeathered wings: causes atrophy
19. Panda breaking lung-shaped axe: can cause
respiratory failure
20. Pandas roasting intestines: enterovirus
21. Sweating pandas: causes signs of infection such as
sweating, malaise, fever and vomiting
22. Line of henchman: linear virus
23. Ox that stepped in poo: fecal-oral transmission
 341

REVIEW QUESTIONS ?
1. A 14-year-old previously healthy girl presents
to the emergency department due to vomiting,
sweating, and muscle weakness. She recently
emigrated from Southeast Asia and has not
received any vaccinations in her life. Her
temperature is 38.6°C (101.5°F). On physical
exam she appears diaphoretic, fatigued, and
drags her left leg as she walks. Her strength
is 1/5 in her left lower extremity, 3/5 in her
right lower extremity, 4/5 in her left upper
extremity, and 4/5 in her right upper extremity.
The physician suspects a Picornavirus infection.
Which of the following is inconsistent with her
condition?
A. Gray matter of the anterior spinal cord has
been damaged
B. Upper motor neuron signs should be
expected
C. The illness may have been prevented with a
live Sabin vaccine
D. Her condition may cause low inspiratory
capacity
E. Sensation to all extremities is likely to
remain intact

• Correct answer: B
• The patient likely has poliovirus based
on the following:
• Vomiting and diaphoresis
• Asymmetric weakness
• Upper motor neuron signs should not
be expected
• Choices A, C, and D are consistent with
poliovirus infection, making them wrong
answer choices
342

Section 39 - Echovirus

1. Echo: Echovirus 9. Henchman stepping on poop: fecal-oral

2. Rainbow: positive sense transmission
3. Warm colors: RNA virus 10. Henchman foaming at the mouth: salivary
4. Icosahedral gems on cane: icosahedral capsid transmission
5. Line of henchman: linear virus 11. Hat knocked off: causes meningitis
6. IRS henchman: contains internal ribosomal entry 12. Asteroid breaking into pieces: one big protein is
site (IRES) cleaved into several smaller functional proteins
7. Naked pigs: naked virus 13. Naked pigs in mud pit: naked viruses enter host cell
8. Pig choking henchman with intestines: considered via endocytosis
an enterovirus
 343

REVIEW QUESTIONS ?
1. A laboratory researcher is studying traits
associated with picornaviruses. She identifies
a member of the picornavirus family that
replicates within Peyer’s patches and can cause
meningitis. Which of the following statements is
true regarding this virus?
A. Proteins surrounding the genome curve
continuously around a center point
B. The virus is considered one of the
enteroviruses
C. There is an absence of uracil in the viral
genome
D. The virion contains an enzyme for
synthesizing nucleic acids

• Correct answer: B
• Enteroviruses replicate within the small
intestine and cause meningitis
• Choice A is incorrect because this describes
a helical capsid
• Choice C is incorrect because this suggests
picornaviruses lack RNA
• Choice D is incorrect because this describes
RNA-dependent RNA polymerase,
something carried only by negative sense
RNA viruses
344
Section 40 - Rhinovirus
1. Warm colors: RNA virus
2. Rainbow: positive sense
3. Rhinos: rhinovirus
4. Peacock emperor: picornavirus
5. Icosahedral gem on cane: Icosahedral capsid
6. Line of rhinos: linear virus
7. Hundreds of rhinos: over 100 serotypes
8. Rhinos burning in acid pit: acid labile
9. Naked henchman: naked virus
10. Henchman in mud pit: naked viruses enter host cell
via endocytosis
11. Asteroid breaking into pieces: one big piece is
cleaved into several smaller functional proteins
12. Coughing IRS henchman: causes cough
13. Congested rhino: causes mucus drainage
14. IRS henchman: contains internal ribosomal entry
site (IRES)
15. Henchman pulling collar: can cause pharyngitis
 345

REVIEW QUESTIONS ?
1. An 8-year-old boy presents with his father
due to a sore throat and a mild cough. The
boy states it has been difficult to swallow due
to pain. The boy’s father complains that the
boy has constantly been wiping his snot on
his clothes for the past week. A rapid antigen
detection test and a culture for group A
Streptococcus (GAS) are both negative. Which
of the following statements is true regarding the
most likely pathogen?
A. Functional virions can be excreted in the
feces
B. Ribosomes translate viral nucleotides
without prior viral transcription
C. Functional virions replicate in the nucleus of
the host cell
D. Host cell ribosomes attach to the 5’ cap to
initiate translation

• Correct answer: B
• The patient most likely has a rhinovirus
infection based on the following:
• Mucus drainage
• Pharyngitis (post-nasal drip)
• Rhinovirus is the most common
cause of a cold
• Rhinovirus is a positive sense RNA virus
which enables it to be translated upon
entry into the cytoplasm
• Choice A is incorrect because rhinovirus
is acid-labile and would not survive long
enough to be excreted in the feces
• Choice C is incorrect because all RNA viruses
replicate in the cytoplasm
• Choice D is incorrect because picornaviruses
lack a 5’ cap, which is why they require an
internal ribosomal entry site
346
Section 41 - Coxsackieviruses (A & B)
1. Cockfight: Coxsackie A and B
2. Peacock emperor: picornavirus
3. Icosahedral gem on cane: icosahedral capsid
4. Warm color: RNA virus
5. Rainbow: positive sense virus
6. Asteroid breaking into pieces: one big protein is
cleaved into smaller functional proteins
7. Line of henchmen: linear virus
8. Blood splatters: causes vesicles on the hands, feet
and oral mucosa (hand-foot-mouth disease)
9. Blood splatters on tail: vesicles can appear on the
buttocks
10. Pig intestine shop: considered an enterovirus
11. Falling and accidentally knocking hat off: can cause
meningitis
12. Muscular and enlarged rooster in cart: can cause
myocarditis and heart failure
13. Fire surrounding cart: can cause pericarditis
14. Wolf with fire on chest: chest pain from myocarditis
or pericarditis
15. Naked pig: naked virus
16. Wolf wrapping arms around naked pig: naked
viruses enter cell via endocytosis
17. IRS henchman: contains internal ribosomal entry
site (IRES)
 347

Photo Creadit James Heilman, MD [CC BY-SA 4.0 (https://

creativecommons.org/licenses/by-sa/4.0)]
Figure 5.4.104 - Coxsackie-related oropharyngeal
vesicular lesions (herpangina)

Photo Credit: Mrradiostar82 [CC BY-SA 3.0 (https://creativecommons.
org/licenses/by-sa/3.0)]
Figure 5.4.102 - Coxsackie-related palmar vesicular
lesions
REVIEW QUESTIONS ?
1. An 8-year-old boy presents to his pediatrician
due to high fevers and a rash on his hands and
feet. His temperature is 40°C (104.0°F). Physical
examination reveals multiple vesicles on the
boy’s palms and soles. The boy complains
of chest pain and shortness of breath. The
physician suspects that coxsackie is the culprit
of the boy’s presentation. Which of the
following statements is not true regarding this
patient’s condition?
A. The chest pain may be due to fluid in the
lungs
B. Vesicles may be present on the buttocks
C. Functional virions will not be found in the
patient’s stool
D. Nuchal rigidity may occur in some infected
patients

• Correct answer: C
• Coxsackieviruses are enteroviruses and
can produce functional virions in the
Photo Credit: Ngufra at English Wikipedia [CC BY-SA 3.0 (https://
stool
creativecommons.org/licenses/by-sa/3.0)] • Choices A, B, and D are all true statements
Figure 5.4.103 - Coxsackie-related plantar vesicular regarding Coxsackiviruses
lesions
348
Section 42 - Hepatitis A Virus
1. “A” shaped palanquin: Hepatitis A
2. Warm colors: RNA virus
3. Rainbow: positive sense
4. Peacock emperor: picornavirus
5. Icosahedral gem on cane: Icosahedral capsid
6. Asteroid breaking into smaller asteroids: one big
protein is cleaved into several smaller functional
proteins
7. Naked pig: naked virus
8. Net wrapped around pig: naked viruses enter the
cell via endocytosis
9. IRS henchman: contains internal ribosomal entry
site (IRES)
10. Line of wolves: linear virus
11. Snowflakes: IgM antibodies against HAV are present
during an acute infection
12. Eggs hatching: short incubation period
13. Traveling daycare: Hepatitis A often infects travelers
14. Daycare children: Hepatitis A often infects daycare
children
15. Crab booth: Hepatitis is often spread through
contaminated shellfish
16. Panda stepping in poo: fecal-oral transmission
17. Panda vomiting in terror: can cause nausea and
vomiting
18. Turtle slapping cigarette down: active Hepatitis A
infections are often associated with aversion to
cigarettes
19. Starving pig: Hepatitis A causes anorexia
20. Wolf with charred fur on only half his body: often
causes jaundice
21. Cow holding abs: causes RUQ pain
22. Councilman attacking cow: liver biopsy shows
Councilman bodies
23. Needles: prevent infection with vaccination
24. Needle poking wolf: vaccinations are warranted as
post-exposure prophylaxis
25. Tiles: post-exposure prophylaxis may include
immunoglobulin administration
26. Water: treat active infection with supportive care
27. Pig in little house: anti-HAV IgG antibodies indicate
immunity
 349

REVIEW QUESTIONS ?
1. An 50-year-old female with a 20-pack-year
history presents to the physician complaining
of abdominal pain, nausea and vomiting.
She endorses recent travel to a developing
country. Just prior to returning home to the
United States, she recalls hearing about a viral
outbreak in that area that caused vomiting.
Her temperature is 38.4°C (101.2°F). Physical
examination is significant for right upper
quadrant abdominal pain upon palpation.
Photo Credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/ Scleral icterus is absent. She denies a history
by-sa/3.0)]
of IV drug use or unprotected sex. Laboratory
Figure 5.4.105 - Councilman bodies in HAV
results are shown below.
AST: 163 U/L
ALT: 182 U/L

2. Which of the following is true regarding the

pathogen most likely responsible for her
symptoms?
A. The period between exposure and symptom
onset is 3-4 months
B. IgM antibodies will develop against
envelope antigens during the acute phase
C. Hepatitis serology would reveal the
presence of anti-HAV IgG antibodies
D. A liver biopsy may reveal eosinophilic
bodies surrounded by normal cells

• Correct answer: D
• The patient likely has a hepatitis A
infection based on the following:
• RUQ pain
• Elevated AST and ALT
• Nausea and vomiting
• Liver biopsy in patients with hepatitis A
infections will likely reveal ballooning
hepatocytes as well as healthy
hepatocytes surrounding eosinophilic
apoptotic bodies (Councilman bodies)
• Choice A is incorrect because has a short
incubation period (< 1 month)
• Choice B is incorrect because hepatitis A is a
naked virus, not enveloped
• Choice C is incorrect because anti-HAV IgG
antibodies indicate immunity
350

TABLES & FIGURES

Table 5.1.1 - Bacterial structures....................................................................................................................... 6
Figure 5.1.1 - Gram positive bacterial envelope................................................................................................ 7
Figure 5.1.2 - Gram negative bacterial envelope............................................................................................... 7
Figure 5.1.3 - Envelope of Mycoplasma spp...................................................................................................... 8
Figure 5.1.4 - Envelope of Mycobacteria spp.................................................................................................... 8
Figure 5.1.5 - Acid-fast stain of Mycobacterium Tuberculosis .......................................................................... 8
Figure 5.1.6 - Bacterial endospore.................................................................................................................... 9
Table 5.1.2 - Overview of virulence factors..................................................................................................... 10
Figure 5.1.7 - Protein A mechanism................................................................................................................ 11
Figure 5.1.8 - Visual demonstration of Type III secretion systems.................................................................. 12
Table 5.1.3 - Bacterial exotoxins...................................................................................................................... 13
Figure 5.1.9 - Exotoxins that inhibit protein synthesis..................................................................................... 14
Figure 5.1.10 - Exotoxins that increase fluid secretion using adenylate cyclase.............................................14
Figure 5.1.11 - Exotoxin (heat-stable toxin) that increases fluid secretion through guanylate cyclase...........15
Figure 5.1.12 - Pertussis toxin mechanism...................................................................................................... 15
Figure 5.1.13 - Mechanism of tetanospasmin................................................................................................. 16
Figure 5.1.14 - Mechanism of botulinum toxin............................................................................................... 16
Figure 5.1.15 - Mechanism of exotoxins that disrupt cell membranes........................................................... 17
Figure 5.1.16 - Mechanism of superantigens.................................................................................................. 17
Table 5.1.4 - Mechanisms of genetic change in bacteria................................................................................. 20
Figure 5.1.17 - Random mutation in bacteria.................................................................................................. 21
Figure 5.1.18 - Phase variation in bacteria...................................................................................................... 21
Figure 5.1.19 - Transformation in bacteria...................................................................................................... 21
Figure 5.1.20 - Conjugation in bacteria........................................................................................................... 22
Figure 5.1.21 - Generalized transduction (lytic cycle)..................................................................................... 23
Figure 5.1.22 - Specialized transduction (lysogenic cycle)............................................................................... 24
Figure 5.1.23 - Restriction modification.......................................................................................................... 25
Figure 5.1.24 - Brain biopsy with vacuolations from spongiform encephalopathy.........................................28
Figure 5.1.25 - Fungi structure........................................................................................................................ 29
Figure 5.1.26 - Filamentous fungus................................................................................................................. 29
Figure 5.1.27 - Mold (left) and yeast (right).................................................................................................... 30
Figure 5.1.28 - Spores of Aspergillus............................................................................................................... 30
Figure 5.1.29 - Enveloped virus structures...................................................................................................... 32
Figure 5.1.30 - Naked virus structures............................................................................................................. 32
Figure 5.1.31 - Adsorption, penetration, and uncoating of naked viruses......................................................33
Figure 5.1.32 - Adsorption, penetration, and uncoating of enveloped viruses...............................................33
Figure 5.1.33 - Bacteriophage structure.......................................................................................................... 33
Table 5.1.5 - Genetic adjustments and activities in viruses............................................................................. 35
Figure 5.1.34 - Genetic shift and genetic drift................................................................................................. 35
Figure 5.1.35 - Phenotypic mixing................................................................................................................... 36
Figure 5.1.36 - HDV superinfection................................................................................................................. 36
Figure 5.1.37 - Positive-sense and negative-sense viruses.............................................................................. 38
Figure 5.1.38 - Poxvirus cytoplasm replication................................................................................................ 39
Figure 5.1.39 - HBV structure.......................................................................................................................... 39
Figure 5.1.40 - RNA virus replication............................................................................................................... 39
 351

Figure 5.1.41 - DNA virus replication............................................................................................................... 40

Figure 5.2.1 - Bacteria overview figure............................................................................................................ 41
Figure 5.2.2 - Gram stain................................................................................................................................. 43
Figure 5.2.3 - Gram-positive bacilli.................................................................................................................. 43
Figure 5.2.4 - Tetanospasmin.......................................................................................................................... 43
Figure 5.2.5 - Gram stain of Clostridium botulinum........................................................................................ 45
Figure 5.2.6 - Gram stain of Clostridium difficile............................................................................................. 47
Figure 5.2.7 - Pseudomembranous colitis ...................................................................................................... 47
Figure 5.2.8 - Gram stain of Clostridium perfringens...................................................................................... 49
Figure 5.2.9 - Gas gangrene ............................................................................................................................ 49
Figure 5.2.10 - Gram stain of Bacillus anthracis.............................................................................................. 51
Figure 5.2.11 - Cutaneous anthrax ................................................................................................................. 51
Figure 5.2.12 - Gram stain of Bacillus cereus................................................................................................... 53
Figure 5.2.13 - Gram stain of gram-positive rods............................................................................................ 55
Figure 5.2.14 - Hemolysis on 5% sheep blood agar......................................................................................... 55
Figure 5.2.15 - Catalase test............................................................................................................................ 55
Figure 5.2.16 - Gram stain of Corynebacterium diphtheriae........................................................................... 57
Figure 5.2.17 - Cystine-tellurite agar............................................................................................................... 57
Figure 5.2.18 - Pseudomembranous pharyngitis............................................................................................. 57
Figure 5.2.19 - Gram stain of Streptococci...................................................................................................... 59
Figure 5.2.20 - Microbial resistance and sensitivity to various compounds....................................................59
Figure 5.2.21 - Splinter hemorrhages.............................................................................................................. 59
Figure 5.2.22 - Quellung reaction.................................................................................................................... 61
Figure 5.2.23 - Otitis media............................................................................................................................. 61
Figure 5.2.24 - Cellulitis................................................................................................................................... 63
Figure 5.2.25 - Impetigo.................................................................................................................................. 63
Figure 5.2.26 - Erysipelas................................................................................................................................. 64
Figure 5.2.27 - Sandpaper-like rash................................................................................................................. 64
Figure 5.2.28 - Strawberry tongue................................................................................................................... 64
Figure 5.2.29 - GAS pharyngitis....................................................................................................................... 64
Figure 5.2.30 - CAMP test................................................................................................................................ 67
Figure 5.2.31 - Gram stain of Enterococci....................................................................................................... 71
Figure 5.2.32 - Gram stain of Staphylococcus.................................................................................................. 73
Figure 5.2.33 - Mannitol fermentation test..................................................................................................... 73
Figure 5.2.34 - Coagulase test tube................................................................................................................. 73
Figure 5.2.35 - Urease test.............................................................................................................................. 75
Figure 5.2.36 - Gram stain of Nocardia........................................................................................................... 79
Figure 5.2.37 - Acid-fast stain of Mycobacterium Tuberculosis (similar to Nocardia).....................................79
Figure 5.2.38 - Gram stain of Actinomyces...................................................................................................... 81
Figure 5.2.39 - Sulfur granule.......................................................................................................................... 81
Figure 5.2.40 - Gram stain of Neisseria........................................................................................................... 82
Figure 5.2.41 - Chocolate agar......................................................................................................................... 82
Figure 5.2.42 - Gram negative bacterial cell wall . .......................................................................................... 83
Figure 5.2.43 - Oxidase test............................................................................................................................. 83
352

Figure 5.2.44 - Chocolate agar and Thayer-Martin agar.................................................................................. 83

Figure 5.2.45 - Gram stain of Moraxella.......................................................................................................... 89
Figure 5.2.46 - Otoscopic view of otitis media................................................................................................ 89
Figure 5.2.47 - Gram Stain of Haemophilus influenzae................................................................................... 91
Figure 5.2.48 - Satellite colonies of Haemophilus influenzae growing near Staphylococcus aureus on blood
agar.................................................................................................................................................................. 91
Figure 5.2.49 - Epiglottis.................................................................................................................................. 91
Figure 5.2.50 - Thumb sign.............................................................................................................................. 92
Figure 5.2.51 - Cherry red epiglottis................................................................................................................ 92
Figure 5.2.52 - Gram stain of Bordetella.......................................................................................................... 95
Figure 5.2.53 - Regan-Lowe agar..................................................................................................................... 95
Figure 5.2.54 - Gram stain of gram-negative coccobacilli................................................................................ 97
Figure 5.2.55 - Granuloma............................................................................................................................... 97
Figure 5.2.56 - Gram stain of Salmonella........................................................................................................ 99
Figure 5.2.57 - TSI agar.................................................................................................................................... 99
Figure 5.2.58 - Peyer’s patches........................................................................................................................ 99
Figure 5.2.59 - Rose spots............................................................................................................................. 101
Figure 5.2.60 - Gram stain of Shigella............................................................................................................ 103
Figure 5.2.61 - Actin...................................................................................................................................... 103
Figure 5.2.62 - Neutrophils............................................................................................................................ 103
Figure 5.2.63 - Schistocytes........................................................................................................................... 103
Figure 5.2.64 - Gram stain of E. coli............................................................................................................... 105
Figure 5.2.65 - Eosin methylene blue aga...................................................................................................... 105
Figure 5.2.66 - MacConkey agar.................................................................................................................... 105
Figure 5.2.67 - Indole test............................................................................................................................. 106
Figure 5.2.68 - Lipopolysaccharide................................................................................................................ 106
Figure 5.2.69 - Mucoid colonies.................................................................................................................... 109
Figure 5.2.70 - Struvite crystals..................................................................................................................... 109
Figure 5.2.71 - Staghorn calculus.................................................................................................................. 111
Figure 5.2.72 - Gram stain of Pseudomonas.................................................................................................. 113
Figure 5.2.73 - Pyoverdin and pyocyanin (bluish-green color) of Pseudomonas (left)..................................113
Figure 5.2.74 - Corneal abrasion................................................................................................................... 113
Figure 5.2.75 - Otitis externa......................................................................................................................... 114
Figure 5.2.76 - Hot tub folliculitis.................................................................................................................. 114
Figure 5.2.77 - Gram stain gram of Yersinia enterocolitica............................................................................ 117
Figure 5.2.78 - Axillary Bubo......................................................................................................................... 117
Figure 5.2.79 - Gram stain of Enterobacter................................................................................................... 119
Figure 5.2.80 - Red pigment from Serratia on a piece of bread.................................................................... 119
Figure 5.2.81 - Warthin-Starry stain.............................................................................................................. 121
Figure 5.2.82 - Gram stain of Legionella........................................................................................................ 123
Figure 5.2.83 - Silver stain of Legionella........................................................................................................ 123
Figure 5.2.84 - Buffered charcoal yeast extract agar..................................................................................... 123
Figure 5.2.85 - Gram stain Campylobacter.................................................................................................... 125
Figure 5.2.86 - Gram stain of Vibrio cholerae................................................................................................ 127
Figure 5.2.87 - “Rice-water” diarrhea........................................................................................................... 127
Figure 5.2.88 - Hematoxylin and eosin (H&E) stain of the gastric mucosa....................................................128
Figure 5.2.89 - Silver based stain................................................................................................................... 128
Figure 5.2.90 - Stomach anatomy and physiology......................................................................................... 129
Figure 5.2.91 - Acid-fast stain of Mycobacterium tuberculosis...................................................................... 131
 353

Figure 5.2.92 - Lowenstein-Jensen medium.................................................................................................. 131

Figure 5.2.93 - Pathophysiology of Mycobacterium tuberculosis.................................................................. 132
Figure 5.2.94 - Miliary tuberculosis............................................................................................................... 133
Figure 5.2.95 - “Serpentine cords”................................................................................................................ 133
Figure 5.2.96 - PPD test................................................................................................................................. 133
Figure 5.2.97 - Ghon complex....................................................................................................................... 133
Figure 5.2.98 - Acid-fast stain of Mycobacterium leprae............................................................................... 135
Figure 5.2.99 - Pathophysiology of Mycobacterium leprae........................................................................... 135
Figure 5.2.100 - Leonine Facies..................................................................................................................... 136
Figure 5.2.101 - Acid-fast stain of Mycobacterium avium-intracellulare.......................................................139
Figure 5.2.102 - Spirochetes via dark-field microscopy................................................................................. 140
Figure 5.2.103 -  Ixodes deer tick................................................................................................................... 140
Figure 5.2.104 - Giemsa stain of Borrelia...................................................................................................... 141
Figure 5.2.105 - Erythema migrans............................................................................................................... 141
Figure 5.2.106 - Bell’s palsy........................................................................................................................... 141
Figure 5.2.107 - Electron microscopic image of Leptospira interrogans.......................................................143
Figure 5.2.108 - Dark-field photomicrograph of Treponema pallidum..........................................................145
Figure 5.2.109 - Chancre............................................................................................................................... 145
Figure 5.2.110 - Maculopapular rash............................................................................................................ 145
Figure 5.2.111 - Maculopapular rash on the palms....................................................................................... 145
Figure 5.2.112 - Condyloma lata.................................................................................................................... 146
Figure 5.2.113 - Gumma................................................................................................................................ 146
Figure 5.2.114 - Cross section of the spinal cord........................................................................................... 146
Figure 5.2.115 - Notched teeth..................................................................................................................... 146
Figure 5.2.116 - Saddle nose......................................................................................................................... 147
Figure 5.2.117 - Rhagades............................................................................................................................. 147
Figure 5.2.118 - Life cycle of Chlamydia trachomatis.................................................................................... 149
Figure 5.2.119 - Giemsa stain of Chlamydia.................................................................................................. 149
Figure 5.2.120 -  Gram stain of Coxiella burnetii........................................................................................... 151
Figure 5.2.121 -  Osler’s nodes...................................................................................................................... 151
Figure 5.2.122 - Clue cells.............................................................................................................................. 153
Figure 5.2.123 - IgM antibodies..................................................................................................................... 154
Figure 5.2.124 - Rocky Mountain Spotted Fever........................................................................................... 156
Figure 5.2.125 - Weil Felix Test...................................................................................................................... 157
Figure 5.2.126 - Ehrlichia within a monocyte................................................................................................ 159
Figure 5.2.127 - Anaplasma within a granulocyte......................................................................................... 159
Table 5.2.1 - Miscellaneous organisms.......................................................................................................... 162
Figure 5.2.128 - Intestinal biopsy in Whipple disease................................................................................... 163
Figure 5.2.129 - Granuloma inguinale caused by Klebsiella granulomatis (male).........................................163
Figure 5.2.130 - Granuloma inguinale caused by Klebsiella granulomatis (female)......................................163
Figure 5.2.131 - Bipolar Donovan bodies from granuloma inguinale ulcer biopsy........................................163
Figure 5.3.1 - Fungi overview figure.............................................................................................................. 165
Figure 5.3.2 - Histoplasma capsulatum yeast in macrophages..................................................................... 166
Figure 5.3.3 - Mold (left) and yeast (right).................................................................................................... 167
Figure 5.3.4 - Verrucous skin lesion............................................................................................................... 169
Figure 5.3.5 - Squamous cell carcinoma........................................................................................................ 169
Figure 5.3.6 - Granulomatous nodule............................................................................................................ 170
Figure 5.3.7 - Broad-based budding by Blastomyces dermatitidis................................................................ 170
Figure 5.3.8 - Endospore of Coccidioides immitis.......................................................................................... 172
354

Figure 5.3.9 - Coccidioides using the methenamine silver stain.................................................................... 173

Figure 5.3.10 - Erythema multiforme............................................................................................................ 173
Figure 5.3.11 - Erythema nodosum............................................................................................................... 173
Figure 5.3.12 - Budding cells of Paracoccidioides brasiliensis....................................................................... 175
Figure 5.3.13 - Hyphae and spores of a dermatophyte................................................................................. 177
Figure 5.3.14 - Tinea capitis........................................................................................................................... 177
Figure 5.3.15 - Tinea corporis........................................................................................................................ 177
Figure 5.3.16 - Tinea pedis............................................................................................................................ 177
Figure 5.3.17 - Vesicular athlete’s foot ......................................................................................................... 177
Figure 5.3.18 - Interdigital tinea pedis........................................................................................................... 178
Figure 5.3.19 - Onychomycosis...................................................................................................................... 178
Figure 5.3.20 - Tinea cruris............................................................................................................................ 178
Figure 5.3.21 - Tinea versicolor skin lesions.................................................................................................. 181
Figure 5.3.22 - Microscopic image of Malassezia furfur “Spaghetti and meatballs” ....................................181
Figure 5.3.23 - Sporothrix schenckii (yeast form).......................................................................................... 183
Figure 5.3.24 - Sporothrix schenckii (mold form).......................................................................................... 183
Figure 5.3.25 - Sporothrix schenckii lesion along draining lymphatic channels ............................................183
Figure 5.3.26 - Pseudohyphae and budding yeast......................................................................................... 185
Figure 5.3.27 - Germ tube formation............................................................................................................ 185
Figure 5.3.28 - Oral thrush............................................................................................................................ 186
Figure 5.3.29 - Esophageal candidiasis ......................................................................................................... 186
Figure 5.3.30 - Vulvovaginitis caused by Candida albicans............................................................................ 186
Figure 5.3.31 - Microscopic morphology of Aspergillus fumigatus............................................................... 189
Figure 5.3.32 - Aspergilloma (gross image)................................................................................................... 189
Figure 5.3.33 - Aspergilloma (imaging).......................................................................................................... 189
Figure 5.3.34 - India ink stain........................................................................................................................ 191
Figure 5.3.35 - Sabouraud dextrose agar....................................................................................................... 191
Figure 5.3.36 - Mucicarmine stain................................................................................................................. 191
Figure 5.3.37 - Microscopy of mucormycosis................................................................................................ 193
Figure 5.3.38 - Silver stain of Pneumocystis jirovecii cysts............................................................................ 195
Figure 5.3.39 - Chest x-rays of Pneumocystis pneumonia with “ground glass” opacities .............................195
Figure 5.3.40 - Pneumatoceles...................................................................................................................... 195
Figure 5.3.41 - Fluorescent antibody stain.................................................................................................... 195
Figure 5.4.1 - Parasites overview figure........................................................................................................ 197
Figure 5.4.2 - Giardia lamblia cyst................................................................................................................. 199
Figure 5.4.3 - Giardia lamblia trophozoite.................................................................................................... 199
Figure 5.4.4 - Red blood cells within Entamoeba cytoplasm (erythrophagocytosis).....................................201
Figure 5.4.5 - Entamoeba egg in stool sample.............................................................................................. 201
Figure 5.4.6 - Cryptosporidium oocysts with acid-fast staining..................................................................... 203
Figure 5.4.7 - Trypomastigotes on peripheral blood smear........................................................................... 209
Figure 5.4.8 - Malaria Life Cycle.................................................................................................................... 211
Figure 5.4.9 - Plasmodium trophozoite ring form within red blood cells .....................................................212
Figure 5.4.10 - Babesia trophozoite ring form (“Maltese cross”) within red blood cells...............................215
Figure 5.4.11 - Barium esophagram showing achalasia................................................................................ 216
Figure 5.4.12 - Cutaneous leishmaniasis....................................................................................................... 219
Figure 5.4.13 - Flagellated Gardnerella trophozoites.................................................................................... 221
Figure 5.4.14 - Gardnerella vaginalis on saline microscopy.......................................................................... 221
Figure 5.4.15 - Pinworm egg.......................................................................................................................... 223
Figure 5.4.16 - Life cycle of parasites that cause Löffler syndrome............................................................... 224
 355

Figure 5.4.17 - Ascaris lumbricoides egg....................................................................................................... 225

Figure 5.4.18 - Strongyloides stercoralis larva............................................................................................... 227
Figure 5.4.19 - Hookworm egg...................................................................................................................... 229
Figure 5.4.20 - Cutaneous hookworm lesion................................................................................................. 229
Figure 5.4.21 - Striated muscle tissue infected with Trichinella spiralis........................................................231
Figure 5.4.22 - Periorbital edema.................................................................................................................. 231
Figure 5.4.23 - Whipworm egg...................................................................................................................... 233
Figure 5.4.24 - Blackfly.................................................................................................................................. 237
Figure 5.4.25 - Elephantiasis.......................................................................................................................... 239
Figure 5.4.26 - Taenia solium life cycle.......................................................................................................... 241
Figure 5.4.27 - Taenia solium on microscopy................................................................................................ 241
Figure 5.4.28 - Taenia solium egg in stool sample......................................................................................... 241
Figure 5.4.29 - Neurocysticercosis on imaging.............................................................................................. 242
Figure 5.4.30 - Echinococcus granulosus life cycle........................................................................................ 244
Figure 5.4.31 - Echinococcus granulosus tapeworm on microscopy............................................................. 245
Figure 5.4.32 - Liver hydatid cyst on MRI...................................................................................................... 245
Figure 5.4.33 - Liver hydatid cyst (gross)....................................................................................................... 245
Figure 5.4.34 - Schistosoma life cycle............................................................................................................ 247
Figure 5.4.35 - Lateral spine on Schistosoma egg (mansoni or japanicom)...................................................247
Figure 5.4.36 - Lateral spine on Schistosoma haematobium egg.................................................................. 247
Figure 5.4.37 - Scabies-related erythematous papules................................................................................. 251
Figure 5.4.38 - Pediculus capitis louse........................................................................................................... 253
Figure 5.4.39 - Pediculus nit on hair shaft..................................................................................................... 253
Figure 5.4.40 - Pediculus pubis louse............................................................................................................. 253
Figure 5.4.41 - Pediculus corporis louse........................................................................................................ 253
Figure 5.4.42 - Virus overview figure............................................................................................................. 254
Figure 5.4.43 - Trigeminal ganglion............................................................................................................... 256
Figure 5.4.44 - Gingivostomatitis................................................................................................................... 256
Figure 5.4.45 - Viral keratoconjunctivitis....................................................................................................... 256
Figure 5.4.46 - Herpetic whitlow................................................................................................................... 256
Figure 5.4.47 - Herpes labialis....................................................................................................................... 257
Figure 5.4.48 - Erythema multiforme............................................................................................................ 257
Figure 5.4.49 - HSV-related esophageal ulcers.............................................................................................. 257
Figure 5.4.50 - MRI of temporal lobe encephalitis........................................................................................ 258
Figure 5.4.51 - Neonatal herpes.................................................................................................................... 258
Figure 5.4.52 - Vesicular and ulcerative herpes lesions................................................................................. 258
Figure 5.4.53 - Multinucleated giant cells on Tzanck smear.......................................................................... 258
Figure 5.4.54 - Cowdry bodies in hepatocytes.............................................................................................. 258
Figure 5.4.55 - Chickenpox............................................................................................................................ 261
Figure 5.4.56 - Shingles................................................................................................................................. 261
Figure 5.4.57 - Herpes zoster ophthalmicus.................................................................................................. 261
Figure 5.4.58 - Cytotoxic T-cells on EBV-related peripheral blood smear......................................................263
Figure 5.4.59 - Starry sky appearance on biopsy of Burkitt’s lymphoma......................................................263
Figure 5.4.60 - MRI showing ring-enhancing lesion...................................................................................... 263
Figure 5.4.61 - CMV retinitis.......................................................................................................................... 265
Figure 5.4.62 - “Blueberry muffin” rash........................................................................................................ 265
Figure 5.4.63 - Periventricular calcifications on CT imaging.......................................................................... 265
Figure 5.4.64 - Owl’s eye appearance on lung biopsy................................................................................... 265
Figure 5.4.65 - Skin lesions in Kaposi’s sarcoma............................................................................................ 269
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Figure 5.4.66 - HBV structure........................................................................................................................ 271

Table 5.4.1 - Descriptions of serologic markers in Hepatitis B....................................................................... 271
Figure 5.4.67 - Serological markers in acute hepatitis B infection................................................................. 272
Figure 5.4.68 - Serological markers in chronic hepatitis B infection.............................................................. 272
Figure 5.4.69 - H&E stain showing ground glass appearance........................................................................ 273
Figure 5.4.70 - Reverse transcriptase in HBV................................................................................................. 273
Figure 5.4.71 - Smallpox................................................................................................................................ 275
Figure 5.4.72 - Umbilicated lesions in Molluscum contagiosum................................................................... 275
Figure 5.4.73 - Plantar warts......................................................................................................................... 277
Figure 5.4.74 - Anal warts.............................................................................................................................. 277
Figure 5.4.75 - HPV carcinogenesis mechanism............................................................................................ 278
Figure 5.4.75 - Koilocytes on Pap smear........................................................................................................ 278
Figure 5.4.77 - Progressive multifocal leukoencephalopathy (PML) on MRI.................................................283
Figure 5.4.78 - Fifth disease........................................................................................................................... 285
Figure 5.4.79 - HIV structure......................................................................................................................... 289
Figure 5.4.80 - HIV replication cycle.............................................................................................................. 290
Figure 5.4.81 - Time course of HIV infection................................................................................................. 290
Figure 5.4.82 - HIV diagnosis......................................................................................................................... 291
Figure 5.4.83 - Fat and lymphoid aggregates seen on HCV liver biopsy........................................................295
Figure 5.4.84 - Lichen planus......................................................................................................................... 295
Figure 5.4.85 - Maculopapular rash of Rubella............................................................................................. 305
Figure 5.4.86 - Chikungunya-related erythematous maculopapular rash.....................................................307
Figure 5.4.87 - Genetic shift and genetic drift............................................................................................... 315
Figure 5.4.88 - Acute HDV-HBV coinfection................................................................................................... 318
Figure 5.4.89 - HDV superinfection............................................................................................................... 318
Figure 5.4.90 - Steeple sign on radiograph in croup...................................................................................... 321
Figure 5.4.91 - Bronchiolitis on chest radiograph.......................................................................................... 323
Figure 5.4.92 - Maculopapular rash in measles............................................................................................. 325
Figure 5.4.93 - Koplik’s spots......................................................................................................................... 325
Figure 5.4.94 - Giant cells.............................................................................................................................. 325
Figure 5.4.95 - Mumps-related parotitis....................................................................................................... 327
Figure 5.4.96 - Rabies virus structure............................................................................................................ 329
Figure 5.4.97 - Rabies virus bullet-shaped envelopes on electron microscopy.............................................329
Figure 5.4.98 - Rabies virus Negri bodies...................................................................................................... 329
Figure 5.4.99 - Retrograde movement of Rabies virus.................................................................................. 330
Figure 5.4.100 - Positive-sense and negative-sense viruses.......................................................................... 339
Figure 5.4.101 - Transmission electron micrograph of Rotavirus.................................................................. 339
Figure 5.4.102 - Coxsackie-related palmar vesicular lesions......................................................................... 347
Figure 5.4.103 - Coxsackie-related plantar vesicular lesions......................................................................... 347
Figure 5.4.104 - Coxsackie-related oropharyngeal vesicular lesions (herpangina).......................................347
Figure 5.4.105 - Councilman bodies in HAV.................................................................................................. 349
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