TOPNOTCH MED BOARD PREP

MICROBIOLOGY AND
PARASITOLOGY
SUPERTABLE
2019 EDITION

By the Topnotch Team

Banzuela, E
Calderon, P
Calderon, E
Mann
Reña
Soberano

1
 No part of this document may be
reproduced or utilized in any form or by
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any information storage and retrieval
system.

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MEDICAL BACTERIOLOGY P. CALDERON, REÑA, SOBERANO

ENCAPSULATED BACTERIA
- capsules serve as an antiphagocytic virulence factor
- are opsonized, and then cleared by spleen
- Asplenics have  opsonizing ability and thus  risk for severe infections
- Give S. pneumoniae, H. influenzae, N. meningitidis vaccines

Some Killers Have Pretty Nice, Elegant, Shiny Bodies

Streptococcus pneumoniae
Klebsiella pneumoniae
Haemophilus Influenzae type B
Pseudomonas aeruginosa
Neisseria meningitidis
Escherichia coli
Salmonella typhi
Group B Strep

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GRAM-POSITIVE COCCI
GRAM-STAIN OTHER FEATURES ORGANISM
CATALASE-POSITIVE ORGANISMS
Catalase-positive
Staphyloccus aureus - Catalase degrades H2O2 into H2O and bubbles of O2 before it can be
Coagulase-positive
Catalase-positive converted to microbicidal products by the enzyme myeloperoxidase
Gram Positive Cocci Coagulase-negative Staphyloccus epidermidis - People with chronic granulomatous disease (NADPH oxidase deficiency)
in Clusters Novobiocin-sensitive have recurrent infections with certain catalase-positive organisms
Catalase-positive
PLACES NBSH
Coagulase-negative Staphyloccus saprophyticus
Novobiocin-resistant Pseudomonas
Listeria
GRAM-STAIN OTHER FEATURES ORGANISM Aspergillus
Catalase-negative Candida
Alpha-hemolytic Streptococcus pneumoniae E. coli
Bile-optochin-sensitive Staphylococci
Catalase-negative Nocardia
Alpha-hemolytic Viridans streptococci B. cepacia
Bile-optochin-resistant
Gram Positive Cocci Catalase-negative
Serratia
Streptococcus pyogenes
in Chains Beta-hemolytic (Group A Beta Hemolytic Streptococcus
H. pylori
Bacitracin-sensitive / GABHS)
Catalase-negative
Streptococcus agalactiae
Beta-hemolytic
Bacitracin-resistant
(Group B Streptococcus / GBS) PIGMENT-PRODUCING BACTERIA
Catalase-negative Actinomyces israelii Yellow “sulfur” granules
Group D Streptoccocci Staphylococcus aureus Yellow pigment
Gamma-hemolytic
Pseudomonas aeruginosa Blue-green pigment
(pyocyanin and pyoverdin)
GRAM-POSITIVE BACILLI Serratia marcescens Red pigment
GRAM-STAIN O2 UTILIZATION OTHER FEATURES ORGANISM
Non-motile
Box-car-shaped Bacillus anthracis
Aerobic Medusa head
Motile
Bacillus cereus
Reheated Fried Rice
Spore-forming Drumstick-, tennis
gram-positive racket-, or lollipop- Clostridium tetani
rods like
Bulging cans Clostridium botulinum
Anaerobic Lecithinase
Double hemolysis Clostridium perfringens
Gas-forming
Pseudomembranes Clostridium difficile
Non-motile
Non-Spore- Corynebacterium
Curved
diphtheria
forming gram- Aerobic Chinese characters
positive rods Curved
Listeria monocytogenes
Tumbling Motility

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 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Staphylococcus Human nose Direct contact (Hands) Catalase-positive IMMUNOMODULATORS: Exofoliatin: causes PYOGENIC: Methicillin-sensitive GRAM-STAIN: 95% resistance to
aureus (anterior nares) To test, rub a wire Protein A: prevents epidermal separation SKIN and SOFT TISSUE INFECTIONS SA (MSSA) reveals gram-positive penicillins
and skin Fomites loop across a colony complement activation; in Scalded Skin  bullous impetigo, folliculitis, furuncles,  Penicillinase- cocci in grape-like
of gram-positive binds IgG, preventing Syndrome carbuncles, cellulitis, hidradenitis resistant cluster 60% MRSA in the
Contaminated food cocci and mix on a opsonization and suppurativa, mastitis, surgical site Philippines
penicillins
slide with H202. If phagocytosis infections CULTURE:
Enterotoxins (heat- (nafcillin, oxacillin,
bubbles appear, - Beta-hemolytic Community acquired
this indicates that stable): superantigens ACUTE ENDOCARDITIS and dicloxacillin)
Coagulase: Allows insoluble causing food - Produces a golden methicillin resistant
H202 is being broken  most common cause of acute
fibrin formation around poisoning Methicillin-resistant yellow colonies on Staphylococcus
down into oxygen endocarditis
organism, protecting it SA (MRSA) blood agar aureus (CA-MRSA)
bubbles and water;  native valve (tricuspid valve) in IV
catalase-positive from phagocytosis Toxic shock  contain altered - “Gold color” is due produces a particular
drug abusers
staphylococci are syndrome toxin penicillin-binding to pigment leukocidin called
Hemolysins (cytotoxins):
present. (TSST-1): superantigen PNEUMONIA protein (PRB) STAPHYLOXANTHIN Panton-Valentine
toxic to hematopoietic cells  nosocomial pneumonia, VAP,  due to resistance Leukocidin
leading to toxic shock
Coagulase-positive necrotizing pneumonia gene mecA Polymerase chain (PVL), which is
syndrome
Leukocidin: specific for  complicated by empyema, abscess or  DOC is reaction (PCR): mecA associated with a
Salt-tolerant on WBCs pneumatocele vancomycin gene for MRSA propensity to form
Alpha toxin: causes
Mannitol salt agar  post-viral pneumonia abscesses
marked necrosis of the
(halotorelant) Catalase: detoxifies Vancomycin-
skin and hemolysis OSTEOMYELITIS and SEPTIC ARTHRITIS
hydrogen peroxide resistant SA (VRSA)
 from hematogenous spread or local
Facultative anaerobe introduction at wound site  DOC is linezolid
Penicillinase: secreted form
 Brodie Abscess: sequestered focus of Causes of
of beta-lactamase; disrupts
osteomyelitis arising in the Necrotizing
the beta-lactam portion of
metaphyseal area of a long bone Pneumonia
the penicillin molecule,
thereby inactivating the TOXIGENIC:  S. aureus
antibiotic GASTROENTERITIS  Pseudomonas
 acute onset (4 hrs) of vomiting and  Aspergillus
TISSUE PENETRANCE: diarrhea due to ingestion of preformed  Viral Pneumonia
Hyaluronidase: "Spreading heat-stable enterotoxin
Factor"; breaks down  source: salad made with mayonnaise
proteoglycans in connective (potato or tuna salad)
tissue (hyaluronic acid)
SCALDED SKIN SYNDROME (Ritter
Fibrinolysin Disease)
(Staphylokinase): dissolves  exfoliatin cleaves desmoglein in
fibrin clots desmosomes
 separation of skin at stratum
Lipase: spread in fat- granulosum (vs TENS/Lyell disease:
separation occurs at dermo-epidermal
containing areas of the
junction)
body
TOXIC SHOCK SYNDROME
Protease: destroys tissue  fever, hypotension, sloughing of
proteins filiform papillae→strawberry tongue,
desquamating rash and multi-organ
involvement (>3)
 usually no site of pyogenic
inflammation; blood CS negative
 tampon-using menstruating women or
in patients with nasal packing for
epistaxis

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 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Staphylococcus Humans (normal Autoinfection Catalase-positive Polysaccharide capsule: Most common cause of: Vancomycin (50% GRAM STAIN: NOVOBIOCIN
epidermidis skin flora) Direct contact (hands) adheres to a variety of - prosthetic valve endocarditis methicillin gram-positive cocci in
Coagulase-negative prosthetic devices; forms a - septic arthritis in prosthetic joints resistance) clusters Sensitive
Facultative anaerobe biofilm - ventriculoperitoneal shunt Epidermidis
infections Removal of CULTURE:
Novobiocin-sensitive Highly resistant to prosthetic device White colonies on Resistant
(Novo SERS) antibiotics blood agar, non- Saprophyticus
hemolytic
Staphylococcus Humans Catalase-positive UTI IN WOMEN Fluoroquinolones GRAM STAIN:
saphrophyticus Coagulase-negative  S. saprophyticus is the 2nd most gram-positive cocci in
Facultative anaerobe
[
common cause of UTI in sexually TMP-SMX clusters
Nitrite-negative active women CULTURE:
(unlike E. coli) Whitish, non-
Novobiocin-resistant hemolytic on blood
(Novo SERS) agar
Streptococcus Humans Respiratory droplets Catalase-negative Hyaluronidase: degrades Erythrogenic toxin: PYOGENIC: DOC is Penicillin G GRAM STAIN: Disease of poverty
pyogenes hyaluronic acid (spreading produces scarlet fever IMPETIGO CONTAGIOSA: perioral Gram-positive cocci in
Bacitracin-sensitive factor) blisters with honey-colored crust; Patients with a chains The antigenic
(B-BRAS) Streptolysin O accumulation of neutrophils beyond the history of rheumatic components of the
Group A Beta- Beta-hemolytic
Bacitracin Streptokinase (fibrinolysin) (oxygen-labile): highly stratum corneum; complication includes fever require long- streptococcal cell
Hemolytic Group B Strep *Anti-streptokinase PSAGN term antibiotic wall:
antigenic, causes AB Lancefield group A
Streptococcus Resistant antibodies decrease efficiency formation; destroys prophylaxis to - C carbohydrate:
ERYSIPELAS: superficial infection
(GABHS) Group A Strep of streptokinase in managing RBCs and WBCs; and is prevent recurrence Positive PYR test for Lancefield
Sensitive MI
extending into dermal lymphatics
the reason for the of the disease PYR test measures typing
CELLULITIS: deeper infection involving hydrolysis of 1-
beta hemolysis - M protein (80
DNase (streptodornase): subcutaneous/dermal tissues; facilitated pyrrolidonyl-B-
*ASO Titers to types): a major
degrades DNA in exudates document antecedent by hyaluronidase (spreading factor) naphthylamide and
or necrotic tissue release of B- virulence factor
PHARYNGITIS PHARYNGITIS: most common bacterial
*Anti-DNAse B to document naphthylamine, which in for the group A
cause of sore throat the presence of p- streptococcus;
antecedent SKIN infection Streptolysin S
TOXIGENIC: dimethylaminocinnamal inhibits the
(oxygen-stable): not dehyde forms a red
C5a peptidase: inactivates SCARLET FEVER: “second disease”; activation of
antigenic compound
complement C5a post-pharyngitic; due to erythrogenic complement and
Advantage: takes <1min protects the
Pyogenic exotoxin A: toxin; seen in lysogenized strains; fever, to determine whether organism from
superantigen similar to strawberry tongue, sandpaper-like the reaction is positive
centrifugal rash, Pastia’s lines, phagocytosis; also
TSST (S. pyogenes or group D
desquamation; Dick test for the weakest point
strep) or negative (all
Exotoxin B: protease susceptibility other Streptococci) in the organism's
that rapidly destroys defense
STREPTOCOCCAL TOXIC SHOCK
tissue → necrotizing SYNDROME: clinically similar but milder ACUTE RHEUMATIC FEVER
fasciitis - Post-pharyngitic Fournier's
than S. aureus TSS; due to pyogenic
gangrene: form of
exotoxin A; recognizable site of pyogenic - Cross-reacting antibodies to M proteins necrotizing fasciitis
inflammation; blood cultures are often and antigens of joint, heart, and brain
involving the male
positive tissue
genital area and
- Diagnosed using the Jones Criteria perineum; often caused
NECROTIZING FASCIITIS: rapidly
by mixed organisms but
progressive infection of deep GLOMERULONEPHRITIS
can be caused by GABHS
subcutaneous tissues; facilitated by - Post-pharyngitic (commonly M12) OR
exotoxin B post-impetigo
- M protein incites immune-complex
IMMUNOLOGIC: deposition
ACUTE RHEUMATIC FEVER - S/S: Hypertension, periorbital edema,
APSGN

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 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
hematuria
Streptococcus Vagina Transvaginally Catalase-negative UTI in pregnant women DOC: Penicillin G Gram-positive cocci in Most common cause
agalactiae / chains of neonatal sepsis in
Group B Transplacentally Bacitracin-resistant NEONATAL PNEUMONIA, SEPSIS, AND Penicillin G + the world (the
(B-BRAS) MENINGITIS: Group B Streptococcus is Aminoglycoside for Beta-hemolytic universe, rather) ☺
streptococcus
the most common cause; predisposing serious infections
Grows using LIM factors include: intrapartum fever >38C, CAMP test–positive: CAUSES OF
broth PROM (>18h), vaginal colonization, and All pregnant women CAMP factor enlarges NEONATAL
complement deficiency should be screened the area of hemolysis MENINGITIS:
Hydrolyzes hippurate for GBS colonization formed by S. aureus  GBS
ENDOMETRITIS → most commonly at 35-37 wks AOG; if  Escherichia coli
polymicrobial; foul-smelling lochia (+), chemo- Lancefield group B  Listeria
prophylaxis with IV monocytogenes
penicillin or
Ampicillin 4h prior
to delivery
Group D Human colon May enter Catalase-negative UTIs due to indwelling urinary catheters Penicillin plus Gram-positive cocci in There is a remarkable
streptococci bloodstream during and urinary tract instrumentation gentamicin chains association between
GIT or GUT surgery Bile and optochin- S. bovis infection
Urethra and female resistant BILIARY TRACT INFECTIONS Vancomycin for Gamma hemolytic and colon cancer
genital tract can be penicillin-resistance colonies
colonized Hydrolyzes esculin in ENDOCARDITIS in patients who
bile esculin agar underwent GIT surgery due to Linezolid for Lancefield group D
(BEA) Enterococcus faecalis vancomycin-
resistant strains Positive PYR test
E. faecalis can grow MARANTIC ENDOCARDITIS in patients
in 6.5% NaCl while S. with abdominal malignancy due to
bovis cannot Streptococcus bovis
Streptococcus Upper respiratory Respiratory droplets Catalase-negative Polysaccharide Capsule: PNEUMONIA: most common cause of Penicillin G Gram-positive Polyvalent (23-type)
pneumoniae / tract retards phagocytosis; major CAP in adults; rust-colored sputum "lancet-shaped" cocci polysaccharide
Pneumococcus Bile and optochin- virulence factor; has 84 Levofloxacin or in pairs or chains vaccine
sensitive OTITIS MEDIA: most common cause in Vancomycin
serotypes; antigenic Alpha-hemolytic
OVRPS (overpass) children combined with Conjugated vaccine:
*Optochin sensitivity IgA protease: for BACTERIAL MENINGITIS: most common Ceftriaxone for Positive Quellung pneumococcal
differentiates Strep colonization cause in adults penicillin resistance reaction: capsular polysaccharide
pneumoniae from swelling when mixed with a coupled with carrier
Viridans strep (since SINUSITIS small amount of antiserum protein (diphtheria
c-substance: reacts with
both are alpha (serum with antibodies to toxoid)
CRP SEPTIC SHOCK: splenectomy predisposes the capsular antigens)
hemolytic)
to sepsis from encapsulated bacteria and methylene blue

No Lancefield antigen

Viridans Oral flora Enters bloodstream Catalase-negative Glycocalyx enhances DENTAL CARIES: S. mutans Penicillin G +/- Gram-positive cocci in OVeRPaSs
Streptococci during dental adhesion to damaged aminoglycoside chains
procedures Bile and optochin- SUBACUTE BACTERIAL ENDOCARDITIS (Gentamicin) OPTOCHIN
heart valves
resistant (SBE): S. sanguis → most common cause Alpha-hemolytic
OVRPS (overpass) of subacute and native valve Vancomycin for Viridans
Viridans strep live in the
Protected from host penicillin-resistance
mouth because they are defenses within endocarditis Resistant
not afraid of the chin vegetations Linezolid for Pneumoniae
(op-to-chin resistant) BRAIN ABSCESSES: S. intermedius vancomycin-
resistant strains Sensitive

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 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Bacillus anthracis Herbivores Contact with infected Aerobic (but since it Protein capsule: polymer of Exotoxin (encoded on CUTANEOUS ANTHRAX: Cutaneous Anthrax: Aerobic, gram-positive Bacillus anthracis is
(zoonotic): animals or inhalation can grow without gamma-D-glutamic acid; plasmin pXO1) - Most common route of entry (95%) DOC is ciprofloxacin box-car shaped rods; the only bacterium
- Sheep of spores from animal oxygen. It is classified antiphagocytic; encoded contains 3 separate - Direct epidermal contact with spores spore-forming; NON- with a capsule
- Goats hair or wool as a facultative on a plasmid called pXO2 proteins, which by causes localized tissue necrosis, Inhalational / MOTILE composed of protein
- Cattle (woolsorter’s disease) anaerobe) themselves are evidenced by a painless round black Gastrointestinal (poly-D-glutamic
nontoxic but lesion with a rim of edema Anthrax: Medusa head acid).
Habitat is soil Human-to-human Virulence depends on together produce the (malignant pustule) Ciprofloxacin or morphology on
transmission has never acquiring 2 plasmids. One systemic effects of - 20% mortality rate Doxycycline with 1 culture: dry “ground Infections result to
been reported. carries the gene for the anthrax: INHALATIONAL/PULMONARY ANTHRAX: or 2 additional glass” surface and permanent immunity
protein capsule (pXO2); the - Edema factor (EF): - inhaled spores from animals antibiotics irregular with (if the patient
other carries the gene for its the active A subunit (Woolsorter’s disease) or from (Rifampin, projections along lines survives)
exotoxin (pXO1) of the exotoxin; Vancomycin, of inoculation
calmodulin- weaponized preparations
(bioterrorism) Penicillin, RAXIBACUMAB:
dependent
adenylate cyclase - prolonged latent period (2mos) Imipenem, Serology monoclonal antibody
- Protective antigen before rapid deterioration Clindamycin, for use in inhalational
(PA): promotes - massively enlarged mediastinal Clarithromycin) PCR of nasal swab anthrax
entry of EF into lymph nodes; pulmonary
phagocytic cells hemorrhage (MCC of death); Vaccine: for high-
Cutaneous Anthrax risk individuals;
- Lethal factor (LF): meningeal symptoms
zinc metallo- - 100% mortality rate without composed of the
MCC of death is
protease that immediate treatment protective antigen
pulmonary
inactivates protein (PA); Animal
GASTROINTESTINAL ANTHRAX: hemorrhage in:
kinase; stimulates vaccine is
- ingestion of live spores leads to UGI - Anthrax
the macrophage to composed of a live
ulceration, edema, and sepsis - Leptospirosis
release TNF-a and strain, attenuated
- vomiting abdominal pain, bloody (Weil’s syndrome)
by loss of its
IL-1B → death diarrhea - Congenital syphilis
protein capsule
PA + EF = Edema Toxin - rapidly progressive course
PA + LF = Lethal Toxin - mortality approaches 100%

Bacillus cereus Endospores No capsule ENTEROTOXINS EMETIC FORM DIARRHEAL FORM Food Poisoning: Aerobic, gram-positive
Heat-labile: similar to Rice Meat, vegetables Symptomatic spore-forming rod;
Spores on grains such the enterotoxin of Short IP: <6 hrs Long IP: >6 hrs treatment only; MOTILE
as rice survive cholera and the LT (mean, 2h) (mean, 9h) food poisoning
steaming and rapid from E. coli; causes Vomiting, nausea, Diarrhea, nausea, is caused by the Culture specimen from
frying ADP-ribosylation, abdominal cramps abdominal cramps pre-formed suspected food source
increasing cAMP enterotoxin
Shorter duration: Longer duration:
Spores germinate
8-10h (mean, 9) 20-36h (mean, 24)
when rice is kept Heat-stable: Ophthalmitis:
Heat-stable Heat-labile
warm for many hours staphylococcal-like Vancomycin
enterotoxin enterotoxin
(e.g., reheated fried enterotoxin functions Clindamycin
Similar to Resembles
rice) → Chinese fried as superantigen Ciprofloxacin
staphylococcal clostridial
rice syndrome Gentamicin
food poisoning gastroenteritis
Resistant to beta-
OPHTHALMITIS: occur after penetrating
lactam antibiotics
eye injuries of the eye with soil-
contaminated object; complete loss of
light perception within 48 h of injury

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 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Clostridium tetani Habitat is soil Endospores: Spores germinate Motile: Flagella (so H- Tetanus Toxin TETANUS Debridement of Anaerobic, gram- Obligate Anaerobes
introduced through under anaerobic antigen-positive) (Tetanospasmin) - “the acute onset of hypertonia or … primary wound positive, spore-forming Can’t Breathe Fresh Air
wound or traumatic conditions in the painful muscular contractions (usually rods, often with an Clostridium
break in the skin wound Tetany occurs after the of the muscles of the jaw and neck) Metronidazole endospore at one end
tetanus toxin is taken up and generalized muscle spasms or Penicillin (see Bacteroides
- Skin popping in IV (terminal spore), giving
drug use at the neuromuscular without other apparent medical notes)
them the appearance Fusobacterium
junction (end plate) and cause” --CDC
- Stepping on a nail is transported to the
of a drumstick, tennis Actinomyces
- strong muscle spasm Tetanus toxoid:
central nervous system racket, or lollipop
- lockjaw (trismus) vaccination with
(retrograde transport).
- risus sardonicus formalin-
There the toxin acts on the
- opisthotonos inactivated toxin
TETANUS PROPHYLAXIS inhibitory Renshaw cell
interneurons, preventing - respiratory muscle paralysis (toxoid), part of the
VACCINATION HISTORY Metronidazole (400
the release of GABA and DPT vaccine; given mg rectally or 500 mg
Uncertain or <3 doses >3 doses
WOUND glycine, which are in childhood and IV every 6 h for 7 days)
Toxoid Toxoid inhibitory NEONATAL TETANUS is defined by the q10yrs thereafter
TIG (ATS) TIG (ATS) is the preferred
(TeANA) (TeANA) neurotransmitters. This World Health Organization (WHO) as “an
inhibition of inhibitory
antibiotic. An
NO (Yes, only illness occurring in a child who has the Antitoxin (ATS): alternative is penicillin
Clean, minor YES NO if last dose NO interneurons allows motor
normal ability to suck and cry in the first 2 human tetanus Requires anaerobic (100,000–200,000
neurons to send a high
given >10y) days of life but who loses this ability immune globulin IU/kg per day),
frequency of impulses to conditions
NO (Yes, only muscle cells, which results between days 3 and 28 of life and becomes (TIG) at the wound although this drug
Contaminated YES YES if last dose NO in a sustained tetanic rigid and has spasms.” site → Passive theoretically may
given >5y) contraction. exacerbate spasms.
Supportive therapy: (Harrisons)
may require
ventilator
assistance

Clostridium Habitat is soil Endospores (heat Anaerobic Motile: Flagella (so H- Botulinum toxin: FOOD-BORNE BOTULISM: eye symptoms Trivalent Botulinum Anaerobic, gram- TRIAD OF BOTULISM:
botulinum resistant) antigen-positive) - heat-labile (BOV, diplopia, ptosis, mydriasis), bulbar Antitoxin (for food- positive, spore-forming - Symmetric
Alkaline neurotoxin signs (diplopia, dysphonia, dysarthria, borne and wound rods descending flaccid
vegetables such as - inhibits release of dysphagia) anticholinergic effects (dry botulism) paralysis (with
green beans, acetylcholine from mouth, constipation, abdominal pain), Culture: requires prominent bulbar
peppers and peripheral nerves → bilateral descending flaccid paralysis, Human botulism: anaerobic condition involvement)
mushroom: flaccid paralysis respiratory paralysis immunoglobulin (thioglycollate- - Absence of fever
Home-canned (descending (for infant botulism) enriched agar) - Intact sensorium
Zip-lock pattern) INFANT BOTULISM: when baby ingests Elimination of the
storage bags - Eight immunologic spores found in household dust or organism from GIT Patient’s serum BOTOX is a
Smoked fish types of toxins honey; due to absence of competitive (Judicious use of injected into mice commercial
- Types A, B, and E: bowel microbes; constipation, flaccid gastric lavage and results in death preparation of
Wild, raw honey: most common in paralysis (FLOPPY BABY SYNDROME) exotoxin A; used in
associated with metronidazole or
humans penicillin) wrinkle removal,
infant botulism - not secreted, rather WOUND BOTULISM: similar to food- torticollis
Bulging canned it is released upon borne except absence of GI prodromal Supportive therapy:
goods the death of the symptoms; due to traumatic incubation and
bacterium implantation and germination of spores ventilator
at the wound site assistance

9
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Clostridium Ubiquitous: Endospores Anaerobic NON-motile Alpha toxin: GAS GANGRENE Gas Gangrene: Anaerobic, gram- Looks motile, but not
perfringens Soil lecithinase (splits - Due to alpha toxin - Wound positive, spore-forming motile on blood agar
GI tract of humans Myonecrosis results lecithin into - Gas produced by anaerobic debridement rods → due to avidity for
and mammals from contamination of phosphocoline and metabolism - Radical surgery lecithin in the blood
wound with soil or diglyceride); cleaves - Pain, edema, and cellulitis with (may require Culture: requires membranes
feces cell membranes crepitation amputation) anaerobic conditions
- Hemolysis and jaundice are common - Penicillin
Food poisoning is 11 other tissue - Hyperbaric Double hemolysis on
transmitted by destructive enzymes FOOD POISONING oxygen blood agar
ingestion of - Due to production of enterotoxin
contaminated food which acts as superantigen Food Poisoning: Growth on egg yolk
- Incubation period: 8-16 hours - Supportive agar: non-motile but
- Watery diarrhea with cramps and PREVENTION: with rapidly spreading
little vomiting Proper wound care growth on culture
- Resolves in 24 hours Adequate cooking media

Clostridium difficile Carried in the Fecal-oral: ingestion of Anaerobic Motile: Flagella (so H- Exotoxins A and B PSEUDOMEMBRANOUS ENTEROCOLITIS: Metronidazole Anaerobic, gram- PO vancomycin
colon: endospores antigen-positive) inhibit GTPases → - antibiotic-associated diarrhea ORAL vancomycin positive, spore-forming because it has poor
- 3% of the general apoptosis and death of - antibiotics suppress normal flora, rods intestinal absorption,
population Hands of hospital enterocytes → allowing C. difficile to overgrow Withdraw causative hence, “coats” the
- up to 30% in personnel are pseudomembranes - Clindamycin, 2nd and 3rd generation antibiotic Exotoxin ins tool lesions with antibiotic
hospitalized important cephalosporins, ampicillin detected by cytopathic
Toxin A: diarrhea Replace fluids effect (final phase by
patients intermediaries - non-bloody diarrhea associated with Infection can
pseudomembranes (yellow-white Surgery if toxic which viral cells infect precipitate flare-ups
Toxin B: cytotoxic to cells) on cultured cells of ulcerative colitis
colonic epithelial cells plaques) on the colonic mucosa megacolon
- toxic megacolon can occur develops or ELISA
Colonoscopy

Corynebacterium Throat Respiratory droplets Facultative anaerobe Pseudo-membrane forms in Exotoxin (encoded by DIPHTHERIA Antitoxins Aerobic, non-spore- Schick test: injection
diphtheriae from carrier the pharynx, which serves ß-prophage); obtained - Mild sore throat with fever initially forming, non-motile of diphtheria
Catalase-positive as a base from where it from a temperate - Pseudomembrane forms on pharynx Penicillin or gram-positive rods; exotoxin into the
secretes its toxin bacteriophage by (results from death of mucosal erythromycin Club or comma-shaped skin, to determine
lysogenic conversion epithelial cells) rods arranged in V or L whether a person is
- Myocarditis Vaccine DPT configuration; looks susceptible to
Subunit A: has ADP-  A-V conduction block - DIPHTHERIA: like Chinese characters infection by
ribosylating activity;  dysrhythmia formalin- diphtheriae
blocks protein - Neural involvement: inactivated Culture:
synthesis by  peripheral nerve palsies exotoxin, as Potassium tellurite:
inactivating EF2 (which  GBS antibodies to the dark black colonies
is involved in translation  palatal paralysis B-subunit are ADP-ribosylation
of eukaryotic mRNA into  neuropathies Loeffler’s medium:
protective ß-prophage
proteins) after 12 hours of
- pertussis growth, stain with Corynebacterium
- tetanus methylene blue. Diphtheriae
Subunit B: provides
entry into cardiac and Reddish
Elongation factor 2
neural tissue metachromatic (Babes- Granules
Ernst / Volutin)
Exotoxin is like a granules can be seen
“human antibiotic”
(inhibits eukaryotic Modified Elek Test:
protein synthesis) for detection of
toxigenicity

10
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Listeria Ubiquitous Ingestion of Facultative anaerobe Motile (via flagella): so has The only gram positive EARLY-ONSET NEONATAL LISTERIOSIS Ampicillin Aerobic, non-spore- Facultative
monocytogenes Plants (vegetables) contaminated raw H-antigen → tumbling bacteria that produces (Granulomatosis Infantiseptica) +/- Gentamicin forming gram-positive intracellular organism
milk or cheese from Catalase-positive motility LPS - transplacental transmission rods, arranged in V- or
Colonizes GI and infected cows - characterized by: TMP-SMX L-shape exhibiting Cell-mediated
female GUT Listeriolysin O: allows  late miscarriage (if allergic to penicillin) tumbling motility immunity is
Vaginally (during escape from the  birth complicated by sepsis, protective
birth) phagolysosomes of multiorgan abscesses, and Narrow zone of beta-
macrophages; major disseminated granulomas NOT hemolysis
Tranplacental virulence factor CEPHALOSPORINS: CAUSES OF
infection of fetus from LATE-ONSET NEONATAL LISTERIOSIS None of the Culture: can grow at NEONATAL
bacteremic mother Internalin: interacts with E- - transmitted during childbirth cephalosporins are temperature as low as MENINGITIS:
cadherin on the surface of - manifests as: active against 4-10C so use cold  GBS
cells  meningitis MRSA, LISTERIA, enrichment technique  Escherichia coli
 meningoencephalitis AND ENTEROCOCCI to isolate from mixed  Listeria
Actin Rockets: propel the flora monocytogenes
bacteria through the ADULT LISTERIOSIS
membrane of one human - second most common cause of
cell into another meningitis in people > 50yo
- most common cause of meningitis in
immunocompromised patients (with
lymphoma, on corticosteroids or
receiving organ transplantation)
- septicemia in pregnant women

GRAM-POSITIVE WITH BRANCHING FILAMENTS

Nocardia asteroides Actinomyces israelii

• Aerobe • Anaerobe
• Weakly Acid fast (Fite-Faraco Stain) • Not acid-fast
• Found in soil • Normal oral, reproductive, and GI flora
• Pulmonary infections in immunocompromised (can mimic • Oral/facial abscesses that drain through sinus tracts
TB but with negative PPD) • Often associated with dental caries/extraction
• cutaneous infections after trauma in immunocompetent • Forms yellow “sulfur granules”
• can spread to CNS → brain abscesses (orange colonies) • Can cause PID with IUDs
• Treatment: Sulfonamides (TMP-SMX) • Treatment: Penicillin
Treatment is a SNAP: Sulfonamides—Nocardia; Actinomyces —Penicillin

11
OTHER CLOSTRIDIA

C. septicum Nontraumatic myonecrosis in immunocompromised patients

C. sordellii Toxic shock syndrome associated with septic abortion
C. tertium Traumatic wound infections

12
 GRAM-NEGATIVE BACTERIA

GRAM-STAIN OTHER FEATURES ORGANISM

Encapsulated
Gram-Negative Ferments maltose and glucose
Neisseria meningitidis
Diplococci Insignificant capsule
Ferments glucose only
Neisseria gonorrheae

Other Neisseriaceae
• Eikenella corrodens and Kingella kingae cause culture-negative subacute bacterial endocarditis in patients with preexisting heart
disease

HACEK Organisms

GRAM-NEGATIVE RODS – RESPIRATORY SYSTEM

GRAM-STAIN OTHER FEATURES ORGANISM
Enriched chocolate agar Haemophilus influenzae
Polyribitol Phosphate capsule type B
Borget-Gengou Agar
Gram-Negative Regan-Lowe medium Bordetella pertussis
Whooping cough
Rods
Poorly gram staining
Silver stain
Charcoal yeast agar
Legionella pneumophila
AIrconditioning

GRAM-NEGATIVE RODS – GIT and GUT

GRAM-STAIN OTHER FEATURES ORGANISM ENTEROBACTERIACEAE
Lactose fermenters
Escherichia coli MESSY SPECK
Green sheen
Lactose fermenters Morganella Serratia
Urease positive Klebsiella pneumoniae Escherichia Proteus
ESBL
Gram-Negative Shigella Enterobacter
Comma-shaped
Rods Microaerophilic Campylobacter jejuni Salmonella Citrobacter
Skirrow’s agar
Yersinia Klebsiella
Comma-shaped
Urease positive Helicobacter jejuni
Microaerophilic Enterobacteriaceae drink COFFEe!
Motile
Oxidase negative Salmonella spp. Capsular antigen (K)
H2S producer O antigen
Non-motile
Oxidase negative Shigella spp.
Flagellar antigen
Non-lactose- H2S non-producer Ferments glucose
fermenting, Gram- Swarming
Enterobacteriaceae
Negative Rods Oxidase negative
H2S producer
Proteus mirabilis
Urease positive
Oxidase positive
H2S non-producer Pseudomonas aeruginosa
Obligate aerobe

13
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Neisseria Upper respiratory Respiratory droplets Ferments both Capsule: Endotoxin (LPS) MENINGITIS: Penicillin Gram-negative, Neisseria
meningitidis tract MALTOSE and  13 serotypes based on  most common cause among aged aerobic, encapsulated, MeninGitidis
High carriage rate in GLUCOSE antigenicity of capsule No exotoxins 2-18 yrs Ceftriaxone (or kidney bean-shaped
Ferments both
HUMANS are the CLOSE QUARTERS: polysaccharides  fever, headache, stiff neck, and cefotaxime): DOC for diplococcus
only natural  Military recruits Oxidase-positive  Serotypes A, B, & C are increased level of PMNs in CSF the treatment of
Maltose and
hosts.  Dormitories colonies on associated with epidemics meningococcal meningitis Culture specimen on Glucose
 Camps chocolate agar of meningitis (usually type MENINGOCOCCEMIA: and septicemia blood agar that has
B)  dissemination of meningococci into been heated to 80°C
Neisseria
Neonates are very Grows best in high the bloodstream Rifampin/ for 15 minutes (called
Ciprofloxacin: chocolate agar) Gonorrhoeae
susceptible from 6 to CO2 environment Endotoxin (LPS): causes  multiorgan disease
prophylaxis Ferments
24 months, when blood vessel destruction  consumptive coagulopathy Selective media:
protective anti- (hemorrhage) and sepsis  petechial or purpuric rash of close contacts of Glucose only
prevents growth of
meningococcal lgG is (purpura fulminans) infected persons
bacteria using Thayer
low. IgA1 protease: cleaves IgA POLYSACCHARIDE
Martin Agar
WATERHOUSE-FRIDERICHSEN VACCINE: CAPSULE:
 Vancomycin: inhibits
Have unique proteins that SYNDROME: contains capsular (+) in Meningococci
G (+)
can extract iron from  most severe form of polysaccharide of (-) in Gonococci
 Colistin and
transferrin, lactoferrin and meningococcemia strains A, C, Y, and
trimethoprim: inhibit
hemoglobin  high fever, shock, widespread W-135 coupled to a AVAILABLE VACCINE:
G (-) except Neisseria
purpura, disseminated carrier protein (+) in Meningococci
 Nystatin: inhibits
Pili: allow attachment to intravascular coagulation, (diphtheria toxoid) to (-) in Gonococci
fungi
human nasopharyngeal cells thrombocytopenia, and adrenal enhance
and undergo antigenic insufficiency → bilateral immunogenicity Cell wall contains Complement
variation to avoid attack by hemorrhagic destruction of the cytochrome oxidase deficiencies in late-
the immune system adrenal glands The first meningococcal which oxidizes dye acting complement
vaccine for serogroup B tetramethylphenylene components (C5-C9)
was approved in diamine from colorless predispose to illness
October 2014. to deep pink. Used to → cannot form
identify colonies membrane attack
complexes
Neisseria Humans only (no Sexually-transmitted Facultative-anaerobe Pili: Endotoxin: GONOCOCCAL URETHRITIS Ceftriaxone plus Kidney bean-shaped N. gonorrhoeae is
gonorrhoeae immunity to  Adherence to epithelial lipooligosaccharide - urethritis and epididymitis in men Doxycycline (to cover with concave sides the most common
repeated Passage through birth Ferments GLUCOSE cells (LOS) - most common cause of urethritis for Chlamydia facing each other cause of hyperacute
infections) canal only  Antigenic variation trachomatis – usual co- forming the appearance bacterial
 Antiphagocytic, binds No exotoxins CERVICAL GONORRHEA infection)) of doughnut conjunctivitis, the
Habitat is the Oxidase-positive bacteria tightly to host cell - in women, which can progress to Gram-negative most severe form of
human genital protecting it from pelvic inflammatory disease (PID) diplococci
Erythromycin conjunctivitis.
tract Grows best in high phagocytosis  Complications of PID
A. Sterility ointment or Silver
CO2 environment Culture: Most common site of
B. Ectopic pregnancy nitrate to prevent
IgA1 protease Specimen on chocolate asymptomatic
C. Chronic Pelvic Pain ophthalmia
agar gonococcal infection
Outer membrane protein D. Dyspareunia neonatorum. Silver
nitrate is no longer used in women:
porins: promote E. Peritonitis Selective media: Thayer
invasion into epithelial cells F. Perihepatitis (Fitz-Hugh-
because it can cause
Martin Agar ENDOCERVIX
chemical conjunctivitis.
Curtis Syndrome) → violin-
Opa proteins: promote string adhesions Cell wall contains
Complement
adherence and invasion into cytochrome oxidase
deficiencies in late-
epithelial cells; expression GONOCOCCAL ARTHRITIS which oxidizes dye
acting complement
results in opaque colonies - the most common cause of septic tetramethylphenylene
components (C5-C9)
arthritis in sexually active diamine from colorless
Have unique proteins that predispose to illness
individuals to deep pink; used to
can extract iron from → cannot form
identify colonies
transferrin, lactoferrin and OPHTHALMIA NEONATORUM membrane attack
PCR in bacterial DNA in
hemoglobin - purulent conjunctivitis in newborns clinical specimens complexes

14
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Moraxella Part of the normal OTITIS MEDIA in children Azithromycin or Resistant to penicilins
(Branhamella flora clarithromycin
catarrhalis) SINUSITIS
BRONCHITIS Amoxicillin with
PNEUMONIA clavulanate

COPD EXACERBATION Oral second or third

generation
cephalosporin

TMP-SMX
Haemophilus Man only Transmitted via Haemophilus Capsule ENCAPSULATED H. INFLUENZAE: Amoxicillin Gram stain: small Haemophilus
influenzae (obligate human respiratory route influenzae requires  6 types, a-f MENINGITIS: +/− clavulanate for gram-negative influenzae is
parasite) two factors for  Type b is most virulent  Most serious manifestation of mucosal infections (coccobacillary) rods formerly called
growth (both found  composed of Hib infection (otitis media, Pfeiffer's bacillus.
The non-typable in blood): polyribitol ribose  Haemophilus influenzae type B is conjunctivitis, Culture specimen on
H. influenzae X factor: Hematin the one of the primary causes of bronchitis) blood agar that has
phosphate
(NTHi) strains V factor: NAD+ meningitis in infants from 3 to 36 been heated to 80oC
colonize the Attachment pili months of age Ceftriaxone for for 15 minutes (now Affects children
nasopharynx in  antecedent upper respiratory tract meningitis called chocolate agar). from 6 months to 1
Satellite growth
up to 80% of infections are common This high temperature year due to decline
around S. aureus lgA1 protease
individuals  Complications: sensorineural Rifampin lyses the red blood in maternal IgG and
colonies hearing loss (6%), mental prophylaxis for close cells releasing both immature immune
retardation, seizure, deafness, contacts hematin (called X system
and death factor) and NAD+
ACUTE EPIGLOTTITIS: Hib vaccine: H. (called V factor). Like
 Most common cause is HiB influenzae the Neisseria, H.
 Cherry-red epiglottis polysaccharide influenzae grows best
 Fever, sore throat, dysphagia, capsule of type b when the chocolate
drooling, and difficulty breathing strain (Hib) is agar is placed in a high
 Thumb sign on X-ray conjugated to CO2 environment at
diphtheria toxoid 37oC
PNEUMONIA:
 insidious onset and a history of given between 2 and
18 months of age Fluorescently labeled
fever, cough, and purulent
antibodies (ELISA and
sputum production
Passive latex particle
CELLULITIS: Immunization: agglunation)
 Most commonly involves the mother is immunized
buccal and periorbital regions; during 8th month of Positive Quellung
usually associated with fever pregnancy to test: due to its
SEPTIC ARTHRITIS in infants increase passive capsule, similar to
antibody transfer in Streptococcus
SEPSIS especially in patients without
breast milk pneumoniae
functioning spleen
NON-ENCAPSULATED H. INFLUENZAE:
OTITIS MEDIA
SINUSITIS
CONJUNCTIVITIS
COPD EXACERBATIONS

15
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Bordetella pertussis Habitat is upper Transmitted via Capsule Pertussis toxin: WHOOPING COUGH Erythromycin Small gram-negative
respiratory tract respiratory droplets  causes ADP - “Tuspirina” (most effective when rods
Beta-lactamase ribosylation - paroxysmal pattern of hacking given in catarrhal
 activates G proteins coughs, accompanied by stage) Culture:
Filamentous hemagglutinin that increases production of copious amounts of Bordet-Gengou agar
(FHA): cAMP resulting in: mucus, that end with an Vaccine: DaPT  potato extract
 pili rod that extends from -  sensitivity to inspiratory “whoop” (Given routinely at
the surface of B. pertussis, histamine ages 2, 4, 6, 15 mos Regan-Lowe charcoal
enabling the bacteria to -  insulin release Incubation Period and between 4-6yo.) medium
bind to ciliated epithelial -  number of  7-10 days  charcoal, blood, and
cells of the bronchi lymphocytes in Pertussis vaccination antibiotic
Catarrhal phase
 mediates attachment blood during pregnancy is
 1-2 weeks
 rhinorrhea, malaise, fever, safe Rapid serologic tests:
Extra-cytoplasmic
adenylate cyclase: sneezing, anorexia (ELISA)
 patient is highly contagious Treat household  Collect specimen
 “weakens”
 Antibiotics most effective contacts with from posterior
neutrophils
erythromycin. pharynx on a calcium
lymphocytes and Paroxysmal phase
monocytes alginate swab since
 2-4 weeks B. pertussis will not
 inhibits  Whoop (burst of non-productive
phagocytosis grow on cotton
coughs)
Filamentous  Increased number of lymphocytes Direct fluorescein-
hemagglutinin: in blood smear labeled antibodies
 allows binding to  Antibiotics ineffective during this applied to
ciliated epithelial stage nasopharyngeal
cells Convalescent stage specimens for rapid
Tracheal cytotoxin:  3-4 weeks (or longer) diagnosis
 kills ciliated  Diminished paroxysmal cough
epithelial cells  Development of secondary PCR detection of
complications (pneumonia, bacterial DNA in
 paralyze cilia
seizure, encephalopathy) respiratory secretions
 causes whooping
Legionella Ubiquitous in man No person-to-person Growth depends on Facultative intracellular Cytotoxins: kill PONTIAC FEVER Azithromycin Aerobic, motile, and Legionnaires disease
pneumophila and natural water transmission the presence of L- parasite hamster ovary cells  mild flu-like illness Levofloxacin nutritionally fastidious (LD) was recognized in
environments cysteine and iron  inhibits macrophage  headache, fever, muscle aches and Doxycycline pleomorphic poorly 1976 after an
 air conditioning PREDISPOSING in special media phagolysosome fusion Endotoxin is sole fatigue gram-negative rods; outbreak of
systems FACTORS: (charcoal yeast  cell-mediated immunity is virulence factor  self-limiting: recovery in a week is visualized with silver pneumonia at an
 cooling towers  Old age important common PREVENTION: stain American Legion
extract agar)
 Smoking Cu-Zn superoxide dismutase  Reducing cigarette convention in
Freshwater  High alcohol intake and catalase-peroxidase ATYPICAL PNEUMONIA and alcohol Serology (IFA and ELISA) Philadelphia.
Optimal growth
amoebae appear  Immunosuppression  protects bacteria from Accompanied by consumption
temperature is 28- Urinary antigen can be
to be the natural macrophage superoxide  confusion  Eliminating aerosols
40°C; organisms are detected by
reservoir for the
dormant below 20°C and hydroperoxide  nonbloody diarrhea from water sources Legionella is non-
radioimmunoassay with
organisms.
and are killed at oxidative burst  hyponatremia  High temperatures encapsulated
high sensitivity and facultative
temperatures above  proteinuria and
Pili and flagella specify and will remain intracellular parasite.
60°C.  hematuria hyperchlorination in
 promote attachment and hospital water
positive for months
invasion after infection. Urine
supply
antigen test only
Secretion of protein toxins detects L. pneumophilia
 like RNAase, serogroup 1, but this
phospholipase A and accounts for 90% of
phospholipase C cases.

16
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Escherichia coli Habitat is human Ascending infection to Indole-positive Fimbriae (pili): attachment/ Endotoxins NEONATAL MENINGITIS UTI: Ampicillin or Facultative Gram- LACTOSE
colon the urethra (UTI) colonization factor; causes  Lipid A portion of Sulfonamides negative rods FERMENTERS
UTI
Lactose-fermenting cystitis and pyelonephritis lipopolysaccharide Grow on MacConKEES
Colonizes the During birth (neonatal colonies on EMB or (LPS) NOSOCOMIAL SEPSIS Meningitis and Sepsis: Beta-hemolytic Citrobacter
vagina and meningitis) MacConkey’s agar Adhesins  Causes septic shock 3rd generation
NOSOCOMIAL PNEUMONIA Klebsiella
urethra cephalosporins Typing by O and H
Fecal-oral (diarrhea) Green metallic Capsule (K-antigen): causes Enterotoxins DIARRHEA antigens Escherichia coli
sheen on EMB agar pneumonia (Exotoxins)  ETEC Aminoglycosides Enterobacter
Colonization of LT (heat-labile): - releases LT and ST toxins
Serratia
catheters in TSI (Triple Sugar Flagella (H-antigen)  increases cAMP - traveler’s diarrhea (watery) Fluoro-quinolones EMB: purple/black
hospitalized patients Iron) agar shows acid (same as cholera MacConkey: pink/purple
Green metallic sheen Siderophore: obtains iron  EPEC
slant and acid butt toxin)
on EMB Aspiration - Watery diarrhea of long duration Rehydration is MOST COMMON
with gas but no H2S from human transferrin or ST (heat-stable) - Mostly in infants, often in effective in traveler’s CAUSES OF NEONATAL
lactoferrin diarrhea
 Increases cGMP developing countries MENINGITIS
Shiga-like toxin (SLT - Flattens villi → prevents  Group B strep
/ verotoxin) absorption  Escherichia coli
PREVENTION:
 inhibits protein  EIEC  Limit urinary  Listeria
synthesis by - Bloody diarrhea catheterization monocytogenes
inactivating the 60S - with pus in the stool and fever  Switch IV lines
subunit of promptly HEMOLYTIC-UREMIC
eukaryotic cells (E.  EHEC/STEC  Drink boiled water SYNDROME
coli O157:H7, STEC, - E. coli strain O157:H7 → MC  Renal Failure
EHEC) serotype  Microangiopathic
- Transmitted via undercooked hemolytic Anemia
HT and LT cause meat  Thrombocytopenia
watery diarrhea - secretes shiga-like toxin
SLT causes bloody (verotoxin) → causes Three Most Common
diarrhea (HUS) hemorrhagic colitis and Causes of Diarrhea in
hemolytic uremic syndrome the World:
- Does not ferment sorbitol  Campylobacter
- no fever, no pus in stool jejuni
 ETEC
 Rotavirus
Shigella species Habitat: human Fecal-oral route No H2S production Invades submucosa of Shiga toxin: BACILLARY DYSENTERY Fluoroquinolones Gram-negative non- IgA is best for
colon only 4Fs: Food, Fingers, intestinal tract (distal ileum  inactivates the 60S  Incubation period: 1-4 days (Ciprofloxacin) motile rods immunity
Feces, Flies Non-lactose and colon), but not the ribosome,  Fever and abdominal cramps → - in severe cases
SHIGELLA SPECIES GROUP fermenter lamina propria → local inhibiting protein diarrhea (initially watery then Have O antigens Shigella is more toxic
inflammation with synthesis and killing bloody) Azithromycin and invasive than
S. dysenteriae
Produce no gas from ulceration → bleeding intestinal epithelial  Diarrhea frequently resolves in 2 or TMP-SMX Cultured in XLD (xylose Salmonella
Type 1 Shiga bacillus Most severe form of
the fermentation of cells 3 days lysine deoxycholate)
bacillary dysentery
A glucose Shigella has a low infective  protein synthesis Fluid and electrolyte medium 4Fs of Shigella
MCC of epidemic
dose (200 bacilli) → highly inhibitor of replacement Transmission:
dysentery
infectious EUKARYOTES Stool culture: because Food
Type 2 Schmitz bacillus
** vs Salmonella with an Shigella is never a part Fingers
Flexner’s bacillus;
of the normal intestinal Feces
B S. flexneri Hiss and Rusell’s infective dose of 105-108
flora Flies
bacillus
Newcastle Invasion of M cells is key
C S. boydii
Manchester bacillus to pathogenicity.
MCC of bacillary
D S. sonnei Duval’s bacillus
dysentery

17
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Salmonella species S. typhi is found S. typhi is transmitted Produces H2S Motile (H-antigen) ENTERO- S. enteritidis/  Invasion of the epithelial and Ceftriaxone Facultative Gram- A. Facultative
only in humans via fecal-oral route COLITIS S. typhimurium subepithelial tissue of small Ciprofloxacin negative rods intracellular parasite:
(colon) Non-lactose Capsule (called the Vi and large intestines 1. Lives within
TMP-SMX
fermenter antigen): protects from  Infectious dose is HIGH WIDAL TEST: detects macrophages in lymph
S. enteritidis is intracellular killing  Gastrectomy or use of Azithromycin antibodies in patient’s nodes
found in enteric antacids lowers infectious serum 2. Can live in gall
tract of humans Siderophores dose significantly In the Philippines, bladder for years
and animals e.g.,  Incubation period: 12-48hr first line drugs for Cultured in XLD (xylose (carriers secrete S.
chickens and  Nausea/vomiting → typhoid: lysine deoxycholate) typhi in stool)
domestic livestock abdominal pain and Amoxicillin medium
nonbloody diarrhea Chloramphenicol B. Persons who are
COURSE OF TYPHOID FEVER TYPHOID S. typhi  Due to Vi capsular antigen TMP-SMX Culture: blood, stool or asplenic or have non-
Week Presentation Culture Source FEVER  Organisms enter, multiply in urine may contain S. functioning spleens
Stepwise fever, anorexia, malaise, relative Blood Peyer’s patches, and then *Salmonella typhi (sickle cell anemia) are
1
bradycardia, and bacteremia Bone marrow spread to RES gastroenteritis: there at increased risk of
Urine  Predilection for invasion of is little benefit from NEVER part of the infection by this
Abdominal pain, bloating, constipation,
2 Rose spots the gallbladder → chronic antibiotic treatment; intestinal flora organism
rose spots, hepatosplenomegaly, jaundice
Bone marrow carrier state it may prolong carrier
Stool  Incubation period: 5-21days state
3 Bleeding ileitis, pneumonia
Bone marrow SEPTICEMIA S. choleraesuis  Bacteremia results in the
PREVENTION:
4 Recovery or death Bone marrow seeding of many organs  Public health
Bile, Stool, bone with osteomyelitis,
POST Chronic carrier state measures: sewage
marrow pneumonia, meningitis as
disposal,
the MC sequelae chorination,
Gold standard for the diagnosis of typhoid fever: BONE MARROW CULTURE  Commonly seen in patients
“The mainstay of laboratory diagnosis for typhoid fever is blood culture, although the handwashing, food
with sickle cell anemia or safety
gold standard is bone marrow culture” (American Society for Microbiology)
“Isolation of Salmonella Typhi from bone marrow is the current gold standard method cancer  Vaccines for S. typhi
for confirming a case of typhoid fever” (WHO)  Fever but with little or no
- Oral: live
enterocolitis → focal attenuated S.
symptoms associated with typhi
affected organ (frequently
- IM: Vi Capsular
bone, lung, or meninges) polysaccharide
Vibrio species V. cholerae: V. cholerae: Oxidase-positive Motile (H-antigen) Choleragen V. CHOLERAE: Cholera: Comma-shaped gram- Pandemics caused by
human colon only Fecal-oral route → Shooting star / fast (enterotoxin): CHOLERA:  Fluid and electrolyte negative rods with a Vibrio cholerae O1
Ferments sugar darting motility like LT of E. coli, acts  severe diarrhea with rice water replacement single polar flagellum biotype El tor
V. parahemoly- V. parahemolyticus: (except lactose) by ADP ribosylation; stools (no pus in stools)  Tetracycline or (cholera El Tor)
ticus and V. Contaminated raw  cAMP, → secretion  Washer woman’s hands sign → Azithromycin Dark field microscopy
vulnificus: seafood Non-lactose of electrolytes from wirnkled skin due to loss of skin shortens duration of stool reveals motile Death by dehydration:
saltwater fermenter the intestinal turgor due to dehydration organism that are children affected in
V. vulnificus: epithelium →  Complications: cardiac and renal V. parahemolyticus immobilized with endemic areas 1991:
Trauma to skin, V. secretory diarrhea failure, non-gap acidosis, and V. vulnificus antiserum Latin America
especially in shellfish parahaemolyticus: Mucinase: digest mucous hypokalemia infection: epidemic
layer so V. cholerae can
V. cholerae: Comma-
handlers, or by halophilic  Minocycline plus Grows as flat yellow 1993: Epidemic in
ingestion of raw attach to cells V. PARAHEMOLYTICUS&VULNIFICUS:
shaped gram-negative, Fluoroquinolone or colonies on selective Bangladesh and India
shellfish GASTROENTERITIS
motile rods with a Fimbriae: helps with Cefotaxime media: Thiosulfate-
ADP ribosylation  Generally self-limited with an
single polar flagellum attachment to cells citrate-bile-salts- Only improvements in
Choleragen activates explosive onset of watery diarrhea
Short term immunity sucrose (TCBS) agar sanitation can lead to
Gs: turns the “ON” on and nausea, vomiting, abdominal
Non-invasive!!! using cholera vaccine effective control of
Pertussis toxin cramps, headache, low-grade fever
→ may cause herd the disease
inactivates Gi: turns WOUND INFECTIONS
Has HIGH infectious dose immunity
the “OFF” off  Associated with exposure to
contaminated water

18
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION

Campylobacter Zoonotic: wild and Uncooked meat Microaerophilic Motile (H-antigen) Enterotoxin: similar to GASTROENTERITIS Symptomatic Microscopic exam of Three Most Common
jejuni domestic animal (especially poultry) cholera toxin and the  Most common cause of bacterial treatment only stool reveals motile, Causes of Diarrhea in
and poultry; Oxidase-positive Invasive: invades the LT of E. coli gastroenteritis curved/comma- or S- the World:
undercooked Unpasteurized milk mucosa of the colon but  Usually caused by ingestion of Erythromycin shaped gram-negative  Campylobacter
chicken Catalase-positive does not penetrate, Cytotoxins: destroy undercooked chicken - for severe disease rods with a single polar jejuni
Fecal-oral therefore, sepsis rarely mucosal cells  Watery, foul-smelling diarrhea flagellum  ETEC
occurs → produces followed by bloody stools Fluoroquinolone  Rotavirus
histologic damage to the accompanied by fever and severe Selective media with
mucosal surfaces of the abdominal pain antibiotic at 42oC:
jejunum  May mimic ulcerative colitis  Skirrow’s agar
Curved, comma- or S- Disease Associations:  Campy’s agar
shaped, gram-negative GUILLAIN-BARRE SYNDROME
rod with a single polar  Antigenic cross-reactivity between Optimum temperature
flagellum oligosaccharides in bacterial is 42oC – to inhibit the
capsule and glycosphingolipids on growth of other fecal
surface of neural tissues species
REACTIVE ARTHRITIS (REITER’S
SYNDROME)
 Triad of:
- Urethritis (can’t pee)
- Uveitis (can’t see)
- Arthritis (can’t climb a tree)
Helicobacter pylori Habitat Is the Transmission is by Microaerophilic Urease: produces No toxin PEPTIC ULCER DISEASE Triple Therapy: Curved gram-negative Urease (+) Bacteria:
human stomach ingestion ammonia; makes the  most common cause of duodenal  Omeprazole rods with a tuft of polar PCHUNKSS
Oxidase-positive environment alkaline → ulcers and chronic gastritis  Clarithromycin flagella (lophotrichous)
 Proteus
helps H. pylori survive in  second leading cause of gastric  Amoxicillin or
Catalase-positive acidic mucosa ulcer Metronidazole EGD with biopsy  Cryptococcus
showing H. Pylori  H. pylori
Urease-positive Damages the goblet cells of Disease Associations: Quadruple Therapy:  Ureaplasma
gastric mucosa  GASTRIC CARCINOMA  Tetracycline Urease breath test,
“Triple Positive”  Nocardia
Lophotrichous flagella  MALT LYMPHOMA  Omeprazole H. pylori stool antigen:
 Metronidazole to document cure  Klebsiella
 Bismuth  S. epidermidis
subsalicylate  S. saprophyticus

19
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Klebsiella Habitat Is the Aspiration or Urease-positive Capsule NECROTIZING PNEUMONIA Culture-guided Facultative gram- 5A’s of KlebsiellA:
pneumoniae upper respiratory inhalation  Friedlander’s Pneumonia treatment negative rods with Aspiration pneumonia
and GIT Indole-negative  Most common cause in alcoholics large polysaccharide Abscess in lungs and
Ascending spread of **vs E. coli which is  Usually nosocomial Cephalosporins +/- capsule liver
fecal flora indole-positive**  Thick, bloody sputum (currant Aminoglycosides
Alcoholics
jelly sputum) Extended spectrum
beta-lactamase (ESBL) Di-A-betics
URINARY TRACT INFECTIONS activity in drug- “Curr-A-nt jelly”
resistant strains sputum
SEPSIS
 Second to E. coli as the common
Very mucoid colonies cause of sepsis
Proteus mirabilis Urease-positive: Motile No toxins COMPLICATED UTI: Ampicilin Facultative gram- WEIL-FELIX
hydrolyzes urea into  UTI associated with nephrolithiasis TMP-SMX negative rod REACTION: a test that
NH3 and CO2 Fimbriae: for adherence  Urease hydrolyzes urea in the urine Surgery: for large stones uses antibodies
to form ammonia →  pH → Culture: Swarming against certain strains
Indole-negative Lipopolysaccharide alkaline urine → struvite stone pattern colonies on BAP of Proteus to diagnose
formation (staghorn calculi; rickettsial disease
Non-lactose Urease production
composed of magnesium- (as certain rickettsiae
fermenter ammonium-phosphate) share similar antigens)
Gram-negative rod with
peritrichous flagella
SEPSIS
Pseudomonas Habitat is Transmission is via Non-lactose Motile (polar flagella) Endotoxin SKIN AND SOFT TISSUE INFECTIONS Combination of active Gram-negative rods, It is the most common
aeruginosa environmental water aerosols, fermenter  Burn wound infections antibiotics required obligate aerobe pathogen isolated
water sources aspiration, and fecal Elastase: causes vascular Exotoxin A  Hot tub folliculitis: spa pools, whirl pools, because of resistance from patients who
e.g., in hospital contamination Oxidase-positive necrosis and local tissue  similar to or inadequately chlorinated swimming to multiple antibiotics Culture: have been
respirators and destruction diphtheria toxin pools and hot tubs  Antipseudomonal  Grown on Cetrimide hospitalized longer
humidifiers Medical devices  inhibits protein  Skin graft loss due to infection penicillins agar than 1 week, and it is
Hands of healthcare Proteases: destroy synthesis by  Green nail syndrome (ticarcillin,  greenish, metallic a frequent cause of
Inhabits the skin, workers antibody and blocking EF2 BONE AND CARTILAGE INFECTIONS piperacillin) colonies on blood nosocomial infections.
upper respiratory complement  causes tissue  Puncture wound osteomyelitis  Penicillin + Beta- agar
tract, and colon of (major pathogen for necrosis  Pubic osteomyelitis in IV drug users lactamase inhibitor  with sweet, fruity Nosocomial
about 10% of nosocomial infections Pyocyanin: damages the  Type III secretion ticarcillin- grape-like odor organisms similar
Ecthyma gangrenosum people because of its cilia and mucosal cells; system facilitates EAR INFECTIONS clavulanate,  produces pigments: to Pseudomonas:
ubiquitous presence generates reactive exotoxin transfer  Most common cause of: piperacillin- - Pyocyanin (blue)  Acinetobacter
Soil, Water, Plants, in the hospital oxygen species - Otitis externa tazobactam - Pyoverdin (green, baumannii
Animals, Intestinal environment) - Malignant otitis externa in diabetics  3rd gen fluorescent  Elizabethkingia
Flora, Skin Verdoglobin: from - Chronic suppurative otitis media cephalosporins: meningo-septicum
hemoglobin breakdown PNEUMONIA ceftazidime  Burkholderia
 Ventilator-associated pneumonia  4th gen cepacia
Hemolysins: lyses RBC  Necrotizing pneumonia (fleur-de-lis cephalosporins:
pattern) cefepime
PSEUDOMONAS
Collagenase  High-risk CAP:  Monobactam:
aztreonam Pneumonia, pyocyanin
- Immunocompromised
Fibrinolysin  Carbapenems: Sepsis
- Broad-spectrum antibiotics
- Steroid therapy imipenem, Ecthyma gangrenosum
Phopholipase C: - Structural lung lesions meropenem, UTIs
degrades cell membranes • Bronchiectasis doripenem, Diabetes, drug use
Green nail syndrome ertapenem
• Cystic fibrosis Osteomyelitis (eg,
DNAse  Fluoroquinolones: puncture wounds)
GASTROINTESTINAL INFECTIONS ciprofloxacin
 Typhlitis (necrotizing enterocolitis) Mucoid
Antiphagocytic

20
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
mucopolysaccharide  Shanghai fever (mild form of typhoid) Examples of suitable polysaccharide
capsule: may contribute  Peritonitis in peritoneal dialysis patients combinations: capsule
to chronic pneumonia in  Ceftazidime + Otitis externa
URINARY TRACT INFECTONS Amikacin
cystic fibrosis patients (swimmer’s ear)
 3 MCC of nosocomial UTIs
rd
 Piperacillin +
due to biofilm formation Nosocomial infections
SEPSIS Amikacin (catheters,
 Ecthyma gangrenosum (hemorrhagic  Azlocillin + equipment)
lesions) Ciprofloxacin Exotoxin A
 Febrile neutropenia Skin infections (hot
- Leukemia or lymphoma post chemo- Rifampicin is added for
tub folliculitis)
or radiation therapy refractory cases
- Severe burns
Bacteroides fragilis Predominant Spreads to blood or Capsular polysaccharide: Lipid A does not elicit Infections commonly due to Metronidazole – DOC Anaerobic, gram- Obligate Anaerobes
anaerobe of the peritoneum during antiphagocytic and a strong host combinations of bacteria in for anaerobic infections negative rods Can’t Breathe Fresh Air
human colon bowel trauma, anticomplement inflammatory synergistic pathogenicity Clindamycin Clostridium
perforation, or response (attenuated) Chloramphenicol
Bacteroides
surgery Succinate: inhibits PMN → LPS with low ABDOMINAL ABSCESS Carbapenems
phagocytosis endotoxic activity 2nd gen FQ Fusobacterium
PERITONITIS Actinomyces
Attachment factors: pili Enterotoxins: causes Surgical drainage of
diarrhea PERICARDITIS abscess Most Common
Chloramphenicol is Bacteria in Colon
ENDOCARDITIS Bacteroides fragilis
static, but cidal to the
following: E. coli
CEREBRAL ABSCESS
 Chloramphenicol is ideal because it
No Bf Since Highschool Enterococcus
is lipophilic N. meningitidis
B. fragilis
S. pneumoniae
H. influenzae

Yersinia Zoonotic: can be Ingestion of Non-lactose Virulence factors are Enterotoxin: MESENTERIC LYMPHADENITIS Antibiotics do not Stool or blood cultures Survives refrigeration
enterocolitica found in pigs contaminated food or fermenter temperature sensitive;  similar to the heat-  in children alter the course of the may be positive
water expressed at 37oC stable toxin (ST) of  pseudo-appendicitis diarrhea. However, Closely related to
E. coli patients with positive Examination of the Yersinia pestis
Unpasteurized milk V and W antigens   cGMP levels ACUTE ENTEROCOLITIS blood culture should terminal ileum with
 with fever, diarrhea (MC be treated with colonoscopy will reveal
Motile manifestation) and abdominal pain antibiotics mucosal ulceration

21
 TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS TOXINS CLINICAL SYNDROMES DIAGNOSIS NOTES
PREVENTION
Brucella spp. Direct contact with Obligate aerobe Non-motile BRUCELLOSIS: Pasteurization of milk Aerobic gram-negative Facultative intracellular
contaminated livestock or  Undulating fever (fever peaks in the coccobacilli parasite
Brucella meltitensis Goats aborted placentas Brucellae are that Tropism for erythritol, a evening, and returns to normal by Treat with combination of
possess a unique ability sugar found in animal morning) doxyxycline Culture blood, bone
(highest pathogenicity)
Ingestion of infected/ to invade both  Weakness and one other drug:
phagocytic and
placentas marrow (best yield), liver,
contaminated/  Loss of appetite - gentamicin or lymph nodes
Brucella abortus Cattle nonphagocytic cells and
unpasteurized dairy - streptomycin
to survive in the Includes ABORTIONS in animals
products intracellular
- rifampin Serologic tests
Brucella suis Pigs
environment by finding
Aerozolization in All cattle are immunized Skin test: Indicates
ways to avoid the
Brucella canis Dogs laboratory or possibly due immune system. with a living attenuated exposure only
to bioterrorism strain of Brucella abortus
Francisella Rabbits and Bite of tick (e.g. Obligate aerobe Capsule antiphagocytic TULAREMIA Streptomycin (DOC) Culture (but very Facultative intracellular
squirrels Dermacentor), deerfly Ulceroglandular: at the site of tick bite Gentamicin dangerous due to its high parasite
tularensis Non-motile infectivity, requires
or infected animals Requires cysteine or direct contact with contaminated rabbit,
Ticks can serve as a an ulcer develops, with swelling of focal Doxycycline addition of cysteine to
reservoir Direct contact with The ability of F tularensis to lymph nodes blood agar media
infected animal tissue impair phagocyte function and Attenuated vaccine: only
survive in infected cells is central for high-risk individuals Skin test
(usually rabbit) Pneumonia: inhalation, or through the
to its virulence. This intracellular
blood
life cycle has been shown to be Measure rise in IgG
Inhaled aerosolized
related to the tightly regulated antibody titer (IgM is not
organisms Oculoglandular: direct inoculation into
expression of a series of genes. very good)
eyes
Ingestion of contaminated
meat or water Typhoidal: ingestion results in
gastrointestinal symptoms (abdominal
Easily transmitted to lab pain) and fever
personnel
Yersinia pestis Wild rodents Flea bite Facultative anaerobe Fraction 1 (F1): this capsular Pesticin: kills other BUBONIC PLAGUE Streptomycin or Gram-negative rods MOST VIRULENT
antigen is antiphagocytic bacteria (including E. coli)  Regional lymph nodes (usually groin) Gentamicin with bipolar staining: BACTERIA!!!
City rats Contact with infected Virulence factors are swell, and become red, hot and tender the ends of these rod-
animal tissue temperature sensitive: V and W proteins Intracellular murine (called a bubo) shaped bacteria take up
only expressed at 37oC
Doxycycline Facultative intracellular
Squirrels and prairie toxin: lethal to mice  high fever stain more than the center parasite
dogs in the US Inhaled aerosolized (temperature inside  conjunctivitis
Non-motile Killed vaccine is (closed safety pin
macrophages)
organisms: human to effective only for a few appearance) Yersinia can accept
human transmission
Requires calcium at 37oC. SEPTICEMIC PLAGUE months (attenuated plasmids in E. coli, and
Virulence is plasmid-
occurs during epidemics  bacteria survive in macrophages, and vaccine is more effective Blood culture shares many antigens
mediated If insufficient calcium, Y. pestis
spread to blood and organs but also has more side with enteric bacteria
alters its metabolism and protein
 death occurs in 75% in untreated effects) Culture bubo aspirate
production. This trait assists with
its intracellular state Subcutaneous
PNEUMONIC PLAGUE Serology hemorrhage result in a
The bacteria elaborate a  during epidemics, pneumonia occurs, as blackish skin
lipopolysaccharide bacteria are spread from person to Rapid diagnostic test: discoloration, giving the
person by aerosolized respiratory antibody against F1 name “Black Death”
endotoxin, coagulase, and a secretion (capsular antigen)
fibrinolysin, which are the  100% fatal if untreated
principal factors in the
pathogenesis of plague.

Pasteurella Part of the normal Bite from dog or cat Facultative anaerobe Capsule WOUND INFECTIONS (following dog Penicillin G Short encapsulated NOT a facultative
flora of domestic and or cat bites): may progress to infection of Doxycycline gram-negative rod that intracellular organism
multocida wild animals Non-motile nearby bones and joints Third generation exhibits bipolar staining
cephalosporin Human bite infection:
Buttery colonies with Eikenella corrodens
musty odor due to
indole production

22

MICROORGANISM RESERVOIR TRANSMISSION METABOLISM VIRULENCE FACTORS
Mycobacterium Habitat is human Transmission is via Produces catalase Mycolic Acid: large fatty acid
tuberculosis lungs inhalation of and niacin
respiratory droplet Mycoside: a mycolic acid
nuclei produced by bound to a carbohydrate
Facultative coughing forming a glycolipid
High lipid content: 40% intracellular growth:
of total cell dry weight is M. tuberculosis can Cord factor
lipid
survive and multiply  a mycoside formed by union
in macrophages of 2 mycolic acids with a
disaccharide (trehalose)
 only found in virulent strain
 most important virulence
factor
 inhibits neutrophil
migration and damages
mitochondria
 may be responsible for
release of tumor necrosis
factor → cachexia
Sulfatides
 mycoside that resemble cord
factor with sulfates attached
to the disaccharide
 exported repetitive
protein
 inhibit phagosome-
lysosome fusion
Wax D
 acts as an adjuvant
 activates the protective
cellular immune system
Tuberculin surface protein:
 Elicits delayed
hypersensitivity
Iron siderophore
(mycobactin)
TREATMENT AND
TOXINS CLINICAL SYNDROMES
PREVENTION
No exotoxin nor TYPES OF LESIONS: (see next page)
endotoxin EXUDATIVE LESIONS
 pus from acute inflammatory DIAGNOSTICS
RAPID CULTURE:
response Bactec radiometric
GRANULOMATOUS LESIONS culture: a liquid broth in a
 central area of Langhan’s type bottle, with radioactive
palmitate as a carbon
giant cells surrounded by a zone of source. Mycobacteria
epithelioid ells grow and use the carbon,
 tubercle is a granuloma surrounded allowing early detection
by fibrous tissue that has (in 1-2 weeks) even
before colonies can be
undergone central caseation
seen.
PPD skin test
PHASES OF INFECTION
Chest X-ray
PRIMARY COMPLEX PCR and DNA probes
 usually in middle or lower lobes
 subpleural granuloma (Ghon’s Mycobacterium Tb Direct
focus) + associated lymph node = Test (MTDT): amplifies
Ghon’s complex ribosomal RNA in
respiratory secretions,
 radiologically detectable
allowing rapid
calcification (Ranke’s complex) identification of M.
REACTIVATION TUBERCULOSIS tuberculosis
 usually in apices (Simon’s focus)
QuantiFERON-TB -
 CXR: cicatrical changes, subpleural measures interferon
blebs, cavitation, fibrosis, nodules gamma levels produced in
o Secondary colonization with whole blood in response
A. fumigatus (fungus ball) to addition of specific
 Can lead to pneumothorax tuberculosis antigens;
relative specificity for
Mycobacterium
SPECTRUM OF DISEASE
tuberculosis; not positive
 Pulmonary tuberculosis in patient in previous BCG
 Miliary tuberculosis vaccination
 Scrofula
 Erythema nodosum Luciferase Reporter
 Tuberculous meningitis Mycobacteriophage
 Spondylitis (Pott’s disease) (LRP) Assays - can
 Gastrointestinal tuberculosis detect M. tuberculosis and
(ileocecal) characterize
 Renal tuberculosis mycobacterial drug
 Abdominopelvic tuberculosis susceptibility patterns
within 24 to 48 h in
positive cultures
(Luciferase is an enzyme
obtained from fireflies)
DIAGNOSIS NOTES
Aerobic, acid-fast, thin, Purified Protein
non-motile rods Derivative (PPD) Test
- Ziehl-Neelsen (or 1. Measure zone of
induration:
Kinyoun)
Positive reaction:
Slow-growing on > 5mm (immune-
Lowenstein-Jensen compromised host)
> 10 mm (have
medium
chronic disease or risk
factors for exposure to
Mycolic acids are also
TB)
found in Nocardia (which
also is acid fast) >15mm (all others)
2. A positive reaction
(“seroconversion”)
indicates:
- current infection /
active disease
- past exposure but
does not mean active
disease
- BCG vaccination
3. Negative Test
indicates:
- no infection
- anergy →
immunocompromised,
malnutrition, steroids,
sarcoidosis
4.PPD skin test is type IV
hypersensitivity mediated
Isoniazid for 9 months
for patients who show
seroconversion but no
clinical symptoms
Bacillus Calmette-
Guérin vaccine is also
used as intravesical
chemotherapy in
patients with bladder
cancer
23
 MYCOBACTERIUM TUBERCULOSIS

Diagnostic Algorithm

Screening of Pediatric Drug-Susceptible Household Contacts of TB

24
 APPROPRIATE SPECIMENS
Pulmonary TB Sputum AFB x 2
TB lymphadenitis Excisional Biopsy
TB Effusion Pleural fluid studies (AFB, Q/Q)
Genitourinary TB Urine AFB
Spinal TB (Pott’s) Tissue Biopsy
Abdominal TB Barium studies for intestinal disease
Abdominal CT for extraintestinal
Peritoneal fluid studies (AFB, Q/Q)
TB Meningitis CSF studies (AFB, Q/Q)
TB Pericarditis Pericardial fluid studies (AFB, Q/Q)

TB DISEASE REGISTRATION GROUPS

MECHANISM OF ACTION OF ANTI-TB DRUGS

Drug Mechanism of Action Mechanisms of Resistance
Rifampicin (RIF) Inhibit DNA-dependent RNA polymerase Mutations in DNA-dependent RNA polymerase
Isoniazid (INH) Inhibit mycolic acid synthesis Mutations of catalase-peroxidase reduce intracellular
transformation to active form
Pyrazinamide (PZA) Interferes with NAD and affects the ETS
Ethambutol (EMB) Inhibit arabinosyl transferase which blocks arabinogalactan synthesis
Streptomycin Interferes with the 30s subunit of ribosomes Mutations of genes encoding the 30s subunit

RECOMMENDED TREATMENT REGIMEN FOR ADULTS AND CHILDREN

MYCOBACTERIUM AVIUM INTRACELLULARE COMPEX (MAI, MAC)

Cause pulmonary disease in immunocompromised hosts (AIDS patients with CD4 <50)

25
DOC: Azithromycin

26
 VIRULENCE FACTORS / SPECTRUM OF DISEASE / TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM DIAGNOSIS NOTES
TOXINS / PATHOGENESIS CLINICAL SYNDROMES PREVENTION
Mycobacterium Humans Prolonged exposure to Catalase-positive Non-motile LEPROSY / HANSEN DISEASE Tuberculoid Leprosy: Aerobic, acid-fast rods
leprae nasal secretions of  most common cause of crippling of the hand Rifampin
Grows best at low
Armadillos patients with Facultative intracellular  Damage in the following nerves is associated Dapsone CANNOT be cultured in vitro. Can
temperature
lepromatous form growth with characteristic impairments in leprosy: only be cultured in certain
Phenolase-positive: - Ulnar and median: clawed hand Lepromatous Leprosy: animals:
converts DOPA into a - Posterior tibial: plantar insensitivity and Rifampin - Mouse footpad
pigmented product clawed toes Dapsone - Armadillo
(used for diagnosis) - Common peroneal: foot drop Clofazimine - Monkeys
 Radial cutaneous, facial, and greater
Feature Tuberculoid Leprosy Lepromatous Leprosy auricular nerves (may also be involved) Skin or nerve biopsy will reveal
limited diffusely over the skin acid-fast bacilli (lepromatous) or
Presentation few hypoesthetic, granulomas (tuberculoid)
Leonine facies
hairless skin plaques Erythema nodosum leprosum ERYTHEMA NODOSUM LEPROSUM
 Seen in lepromatous form Lepromin skin test - Although not
Number of Lesions One or few Many lesions
 Tender red nodules or humps on both shins useful for diagnosis, it allows
Tissue Destruction Little Marked  Signals acute flare-ups of disease positioning of patients on the
Number of acid-fast  Treated with Thalidomide immunologic spectrum
Few Many - Category X drug
bacilli
Likelihood of - Associated with phocomelia if given
Low High during pregnancy
transmitting leprosy
Cell-mediated
Present Reduced or absent
response to M. Leprae
Immune response Th1-type Th2-type
Lepromin Test Positive Negative
Rifampicin + Rifampicin + Dapsone +
Treatment
Dapsone Clofazimine

Mycoplasma Habitat is human Respiratory droplets Aerobic Protein P1 adhesin ATYPICAL PNEUMONIA (WALKING Macrolides NOT SEEN ON GRAM STAIN Mycoplasma has
pneumoniae respiratory tract  Toll-like receptor 2 protein PNEUMONIA) (erythromycin,  No cell wall limited biosynthetic
Requires STEROL for  adheres to epithelial cells of  Mycoplasma pneumoniae is the most azithromycin,  Only bacteria with cholesterol capabilities.
tiniest free-living membrane formation the respiratory tract common cause of atypical pneumonia clarithromycin) in cell membrane
organisms capable of  causes inhibition of ciliary  insidious onset, headache, dry, They can be grown in
self-replication motion (ciliostasis) and nonproductive hacking cough, patchy or Tetracyclines High titer of cold agglutinins cell-free media.
necrosis diffuse interstitial infiltrate (doxycycline) (IgM), which can agglutinate or lyse
 Chest X-ray will show patchy infiltrates that RBCs
Hydrogen Peroxide look worse than clinical findings Quinolones CULTURE:
 contributes to the damage (ciprofloxacin,  Eaton’s agent
to the respiratory tract cells TRACHEOBRONCHITIS levofloxacin)  takes 2-3 weeks
 Requires cholesterol and nucleic
Motile (glides) EXTRAPULMONARY MANIFESTATIONS
acids
 Stevens-Johnson Syndrome (most common PENICILLIN AND
Community-acquired  Add penicillin to inhibit growth
infectious cause is M. pneumoniae) CEPHALOSPORINS
respiratory disease toxin of contaminating bacteria
 Erythema multiforme  do NOT work as
(CARDS)  Dome-shaped colonies with
 Hemolysis mycoplasma does not
 An exotoxin “fried egg” appearance or
 Raynaud’s have a cell wall
 Major role in damage to the  Guillain-Barre syndrome “mulberry” appearance (in the
case of Mycoplasma pneumoniae)
respiratory epithelium
 ADP-ribosylating and Children with sickle cell disease and functional Complement fixation test
vacuolating cytotoxin asplenia may be at greater risk for severe
similar to pertussis toxin. respiratory tract disease PCR/Nucleic acid probes

27

MICROORGANISM
Treponema Habitat is the
pallidum pallidum human genital
tract
Pathogenic treponemes
are associated with the
following diseases:
T. pallidum pallidum:
Venereal syphilis
T. pallidum pertenue:
Yaws
T. pallidum endemicum:
Endemic syphilis (bejel)
T. carateum: Pinta
BORRELIA RECURRENTIS
Relapsing Fever
 rapid antigenic changes due to programmed rearrangements of bacteria DNA encoding surface proteins
 transmitted by human body louse (Pediculus humanus)
 Diagnosed by microscopy
 DOC: Tetracycline or Erythromycin
VIRULENCE FACTORS / SPECTRUM OF DISEASE / TREATMENT AND
RESERVOIR TRANSMISSION METABOLISM DIAGNOSIS NOTES
TOXINS / PATHOGENESIS CLINICAL SYNDROMES PREVENTION
Sexual Microaerophilic Motile PRIMARY SYPHILIS Benzathine Penicillin G Coiled spirochete / thick rigid FALSE-POSITIVE VDRL
 Within hours, enters lymphatics and spirals RESULTS
Transplacental Highly sensitive to multiplies Erythromycin Viruses (EBV,
elevated  Local non-tender / painless chancre Not seen on Gram stain Hepatitis)
temperatures - Versus painful chancroid of H. ducreyi Doxycycline  Too thin Drugs (Marijuana)
SECONDARY SYPHILIS Rheumatic fever,
 maculopapular rash on palms and soles Jarisch-Herxheimer Cannot be cultured in vitro: Rheumatoid arthritis
 Condylomata lata: painless, wart-like lesion  lacks tricarboxylic acid (Kreb’s)
reaction: acute Lupus, Leprosy
which occurs in warm, moist places (vulva or cycle
worsening of symptoms
scrotum) after Penicillin is started;
 Occurs after 1-3 months DARKFIELD MICROSCOPY: most
due to lysis of
 Fever, headache, malaise, anorexia, important (definitive) diagnostic
treponemes
lymphadenopathy test for primary syphilis The antigens in non-
treponemal tests
LATENT SYPHILIS contain measured
NON-TREPONEMAL TESTS:
 25% may relapse back to the secondary amounts of
VDRL, RPR
stage cardiolipin,
 Screening test for syphilis
TERTIARY SYPHILIS  Correlates with disease activity cholesterol, and
 many years after inoculation  Used to monitor treatment purified lecithin in
 granulomas (gummas) of skin and bone 􀂙 quantities sufficient to
 Cardiovascular syphilis (aortitis) TREPONEMAL TESTS: yield a standardized
- Obliterative invasion of small blood FTA-ABS, TPHA amount of reactivity.
vessels and vasa vasorum, causing  Confirmatory test Historically, the
endarteritis  DO NOT repeat even after cardiolipin was
 Neurosyphilis treatment extracted from beef
- Tabes dorsalis  Remain positive throughout life heart or liver with
o Argyll-Robertson pupil (prostitute despite treatment added lecithin and
pupil; can accommodate but do not cholesterol to enhance
react) VDRL: Venereal Disease Research
reaction with syphilitic
- Dementia paralytica Laboratory; RPR: Rapid Plasma Reagin; “reagin” antibodies.
Fluorescent Treponemal Antibody Reagin is a mixture of
CONGENITAL SYPHILIS ABSorption (FTA-ABS); Treponema Pallidum IgM and IgG antibodies
 Snuffles/saddle nose Haemagglutination Assay (TPHA) reactive with the
 Mulberry molar cardiolipin–cholesterol–
 Hutchinson triad (Hutchinson teeth, lecithin complex.
sensorineural hearing loss, interstitial Take Note!!!
keratitis) FTA-ABS
 Saber shins - Most specific
 Rhagades - Earliest positive
 Higoumenakis sign (unilateral enlargement - Remains positive longest
of the sternoclavicular portion of the clavicle
→ detachment)
 Clutton’s joints (synovitis)
 Pulmonary hemorrhage (MCC of death)
28
 VIRULENCE FACTORS / SPECTRUM OF DISEASE / TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM DIAGNOSIS NOTES
TOXINS / PATHOGENESIS CLINICAL SYNDROMES PREVENTION
Borreliella Animal Bite from deer ticks Microaerophilic LYME DISEASE Early Localized or Weakly staining, gram-negative Thiomargarita
burgdorferi Reservoirs: (Ixodes ticks) Stage 1: Early localized stage Disseminated Lyme spirochetes namibiensis is the
 White-footed - Together with  Erythema chronicum migrans (ECM) Disease: largest bacteria ever
Largest medically mouse Babesia microti Doxycycline (DOC) Stains well with aniline dyes discovered (not
important bacterium  White-tailed Stage 2: Early disseminated stage Amoxicilin (Giemsa or Wright stain) medically important).
deer Ixodes scapularis:  Multiple smaller ECM Cefuroxime BAKE a Key LYME Pie
East & Midwest  Neurologic: aseptic meningitis, cranial nerve Cultured on Barbour-Stoenner-
palsies (Bell’s palsy), and peripheral
Bell’s Palsy
Late Manifestations: Kelly (BSK) medium
Ixodes pacificus: neuropathy Arthritis
IV Penicillin
West coast  Cardiac: transient AV block or myocarditis Ceftriaxone (for Elevated levels of antibodies Kardiac Block
 Brief attacks of arthritis of large joints neurologic disease) against Borellia burgdorferi can be Erythema chronicum
(knee) detected by: migrans
 ELISA
Stage 3: Late stage
 Western immunoblotting
 Autoimmune migratory polyarthritis (onion PREVENTION:
 Insectides
skin lesion)
 Insect repellents
 Acrodermatitis chronica atrophicans
 Protective clothing
 Encephalopathy

Leptospira Zoonotic (dogs, Direct contact with Obligate aerobe Leptospires penetrate intact Incubation Period: 2-20 days Mild Leptospirosis: Thin-coiled spirochetes The traditional system
interrogans cats, livestock, and infected urine or (the other spirochetes mucous membranes or skin  Doxycycline divided the genus into
wild animals) animal tissue: are microaerophiles) through small cuts or ACUTE LEPTOSPIREMIC PHASE: Spiral shaped, with hooks on both 2 species: the
 Ampicillin
Organism penetrate abrasions  organisms in blood and CSF ends (“ice tongs”) → Shepherd’s pathogenic Leptospira
 Amoxicillin
broken skin (i.e. on   causes high spiking temperature, chills, crook appearance interrogans and the
feet) and mucous Multiply rapidly and damage intense headache nonpathogenic
endothelium of small blood  rapid multiplication of leptospires in Severe Leptospirosis:
(The resting site membranes Darkfield Microscopy: insensitive; Leptospira biflexa.
for leptospires in (swallowing urine- vessels (VASCULITIS) muscles with high oxygen tension → severe  Penicillin G not recommended
the natural host is contaminated water) muscle aches (calf tenderness)  Ampicillin
the lumen of the Organisms found in:  damaged and leaky conjunctival vessels →  Ceftriaxone Microscopic agglutination Test:
Two axial flagella wrap nephron tubules.) History of wading in blood and CSF (early in the conjunctival suffusion (painful and itchy  Cefotaxime  LeptoMAT
around and run along flood water (in 3rd disease) and in the but with minimal tearing)  the gold standard / criterion
the length of the world setting) urine (later stages) Jarisch-Herxheimer standard for serologic
organism under the IMMUNE LEPTOSPIRURIC PHASE: identification of leptospires
reaction may develop
outer membrane History of exposure to Immune complex-mediated  correlates with emergence of IgM within hours after starting
(periplasmic flagella) animals (butcher) meningitis and  involves recurrence of the above symptoms CULTURE:
therapy
glomerulonephritis  aseptic meningitis  Grown on Ellinghausen-
- CSF pleocytosis with or without McCullough-Johnson-Harris
meningeal symptoms PREVENTION: (EMJH) medium or Fletcher’s
- Coincides with appearance of antibody  Doxycycline for medium
titer postexposure  only becomes positive after 2
 Pulmonary involvement chemoprophylaxis weeks of incubation
- Snowflake lesions on CXR  Rat control  First week: culture blood or CSF
 Hepatic necrosis  Vaccination of domestic (on lab media, or by inoculation
 Glomerulonephritis (due to immune livestock and pets into animals
complex deposition  Second week to months: culture
urine
WEIL’S SYNDROME:
 most severe form of leptospirosis Antibody based ELISA to detect
 triad: Bleeding, Jaundice, Uremia Leptospira antigens in the urine
 orange cast skin (severe jaundice)
 MCC of death: respiratory failure due to Polymerase Chain Reaction (PCR)
massive pulmonary hemorrhage to detect bacterial DNA in serum,
CSF and urine

29
 VIRULENCE FACTORS / SPECTRUM OF DISEASE / TREATMENT AND
MICROORGANISM RESERVOIR TRANSMISSION METABOLISM DIAGNOSIS NOTES
TOXINS / PATHOGENESIS CLINICAL SYNDROMES PREVENTION
Chlamydia Habitat is the Sexual Energy parasites Obligate intracellular TRACHOMA GENITAL AND EYE Gram-negative TRACHOMA
trachomatis human genital that use host ATP bacteria  C. trachomatis types A-C INFECTIONS: lacks classic peptidoglycan layer TYPES A, B, C
tract and eyes During passage  leading infectious cause of blindness Doxycycline (use only due to reduced muramic acid Africa
A-C: trachoma through birth canal Resistant to lysozyme (since  Chronic keratoconjunctivitis for adults) (rendering Beta-lactam antibiotics
Blindness
D-K: genital, neonatal (C. trachomatis is their cell wall lacks muramic  scarring of the inside of the eyelid, resulting ineffective)
strictly human Hand-to eye contact in redirection of the eyelashes onto the
Chronic infection
L1-L3: LGV acid) Erythromycin (especially
pathogen) corneal surface → corneal scarring and for infants and pregnant Cytoplasmic inclusions in
Prevents phago–lysosome blindness woman) Giemsa: (Halberstaedter-
FORMS: fusion  Scraping from the surface of the conjunctiva Prowazek inclusions)
ELEMENTARY BODY RETICULATE (INITIAL) BODY will show round to oval intracytoplasmic Azithromycin
Non-motile inclusion bodies within conjunctival Can classically be grown in chick
Inactive Metabolically active
Extracellular Intracellular No pili epithelial cells (Halberstaedter-Prowazek For STD, add yolk sacs: More commonly
Enters the cells by endocytosis Seen microscopically inclusions) CEFTRIAXONE for chlamydia is cultured in certain cell
No exotoxins possible concomitant lines (McCoy cells for example)
Infectious Replicates the binary fission
GENITAL TRACT INFECTIONS gonorrhea - To enhance the sensitivity of
Elementary body: Enfectious, Enters the cell via Endocytosis
Reticulate body: Replicates in cell by fission, Reorganizes into
PATHOGENESIS:  C. trachomatis types D-K McCoy cells to C. trachomatis
 balance that is often  Most common cause of STDs Note: Systemic treatment growth, cycloheximide was
elementary bodies. reached between host and  Men: Nongonococcal urethritis, epididymitis is required for any added to culture medium for
parasite, resulting in and prostatitis chlamydial eye infection. cultivating infected cells.
prolonged persistence of  Women: Urethritis, cervicitis and pelvic This is especially true for
infection inflammatory disease (PID) infants, who can develop PCR
 Infection persists in the  Associated with Reiter’s syndrome: triad chlamydial pneumonia
presence of high antibody of conjunctivitis, urethritis, and arthritis following chlamydial Nucleic acid amplification test
titer  Birth complications: neonatal pneumonia, conjunctivitis. (NAAT)
neonatal conjunctivitis
NEONATAL PNEUMONA
 C. trachomatis types D-K
 Late-onset (2-4 weeks)
 Striking tachypnea, characteristic
paroxysmal cough (staccato cough),
absence of fever, and eosinophilia
LYMPHOGRANULOMA VENEREUM
 C. trachomatis types L1-L3
 Papule or vesicular which ulcerates leads to
Elementary body (EB): dense spherule that infects cells
Initial (reticulate) body: After EB enters cell, it transforms into an initial suppurative inguinal lymphadenitis
body; larger, osmotically fragile; can produce via binary fission; (buboes)
requires ATP from the host. The initial body transform back into EB,  (+) Frei test: intradermal injection of antigen
which leaves the cell to infect the other cells.

Chlamydophila Humans (spread Respiratory route Life cycle similar to ATYPICAL PNEUMONIA Doxycycline Examine blood for elevated titers TWAR: Taiwan Acute
pneumoniae from human to Chlamydia  Viral-like atypical pneumonia (similar to a of antibodies with complement Respiratory agent
(strain TWAR) human) trachomatis Mycoplasma pneumonia) in young adults Erythromycin fixation and immunofluorescence
tests
Associated with atherosclerosis, meningo- Intracytoplasmic inclusion bodies
encephalitis, arthritis, myocarditis, Guillain- that DO NOT STAIN with iodine
Barre syndrome
Chlamydophila Parrots, parakeets, Humans are infected PSITTACOSIS (BIRD FANCIER’S DISEASE) Azithromycin
psittaci macaws, cockatiels by inhaling Chlamydia-  Sudden onset pneumonia with malaises,
laden dust from fever, anorexia, sore throat, photophobia,
feathers or dried-out and severe headache
feces.

30
 RICKETTSIAE

 Classical detection using Weil-Felix Reaction (cross-reaction with antigens of OX strains of Proteus mirabilis)
 Drug of choice for all rickettsial infections is DOXYCYCLINE.

DISEASE CAUSE VECTOR INCUBATION ONSET RASH ESCHAR MORTALITY

Rocky mountain Macular with centripetal
Rickettsia rickettsii Tick 7 Abrupt NO 10-25%
spotted fever spread
Mites
Rickettsial pox Rickettsia akari
(chiggers)
9 - 14 Abrupt Generalized papulovesicular YES Low

Rickettsia Macular with centrifugal

Epidemic typhus prowazekii
Body louse 8 Abrupt
spread
NO 20

Endemic typus Rickettsia typhi Rat flea 7-14 Gradual Maculopapular NO Low
Orientia Mites Maculopapular with
Scrub typhus 10-12 Abrupt NO 1-15%
tsutsugamushi (chiggers) centrifugal spread
Q fever Coxiella burnetti None 4-90 Chronic None NO 65%
Erhlichia
Ehrlichiosis chaffeensis
Ticks 7-21 Abrupt Maculopapular or petechial NO 2-3%

Only one without vector: Q fever

Only one with chronic onset: Q fever Q fever is Queer because:
Only one without rash: Q fever 1. No rash
Has highest mortality: Q fever 2. No vector
3. Negative Weil-Felix reaction
Only one with gradual onset: Endemic typus
4. Not obligate intracellular
Only one with eschar: Rickettsial pox 5. Does not have Rickettsia in its genus name

Rocky mountain sPotted Fever Palm and Sole Rash

Rash starts in wRIst You drive CARS using your palms and soles
Spreads centriPetally Coxsackievirus type A
Rocky mountain spotted fever
TyPHUs Syphilis
Rash starts in Trunk
Spreads centriPHUgally

MISCELLANEOUS BACTERIA

MICROORGANISM MORPHOLOGY DISEASE CLINICAL FINDINGS OTHERS

Bartonella henselae
Ehrlichia chaffeensis
Gardnerella vaginalis
Haemophilus ducreyi
Yersinia enterocolitica
Klebsiella granulomatosis
Gram-negative rod
obligate intracellular gram-
negative bacterium
Forms morulae in cytoplasm of
monocytes
Facultative gram-variable rod
Small gram-negative rod
Culture on chocolate agar with
Heme (Factor X)
Gram-negative rod
Encapsulated, pleomorphic gram-
negative bacillus
Bipolar densities (Donovan
bodies) look like closed safety
pins
Cat-scratch Disease
Ehrlichiosis
Bacterial vaginosis
Chancroid
Mesenteric adenitis
Granuloma inguinale
(Donovanosis)
Cat-scratch fever in Normal oral flora of cats
immunocompetent hosts Transmitted via cat bite or
Bacillary angiomatosis in scratch
immunocompromised
Malodorous fishy vaginal Associated with sexual
discharge activity, but not sexually
(+) Amine Whiff test (mixing transmitted
discharge with 10% KOH
enhances fishy odor) Treatment:
(+) Clue cells Metronidazole
Painful genital ulcer
Pseudoappendicitis Reservoir: domestic
animals
Transmitted via oro-fecal
route
Small painless papule ulcerates Treatment:
to form beefy red ulcer with Azithromycin
velvety surface
Pseudobuboe formation

31
 ANTIMICROBIALS

ANTIMYCOBACTERIAL DRUGS

ANTIFUNGALS

32
MEDICAL MYCOLOGY P. CALDERON, REÑA, MANN, SOBERANO
FUNGI
 eukaryotic organisms (true nucleus, 80s ribosomes, mitochondria)
 Differences targeted by antifungals include:
1. Fungal cells have cell walls (CW).
a. Fungal cell walls protect cells from osmotic shock, determine
cell shapes, and have components that are antigenic.
b. Fungal cell walls are composed primarily of complex
carbohydrates such as chitin with glucans and mannose-
proteins.
c. The CW glucan (not found in humans) is the antifungal target
of the echinocandins like caspofungin.
2. Ergosterol is the dominant fungal membrane sterol rather than
cholesterol, which is an important difference targeted by
imidazoles, triazoles, and polyenes antifungals.
 Fungi include organisms called molds, mushrooms, and yeasts.
• HYPHAE are filamentous (tubelike) cells of molds (also known as
the filamentous fungi) and mushrooms. Hyphae grow at the tips
(apical growth).
- Septae or septations are cross walls of hyphae and occur in
the hyphae of the great majority of the disease-causing fungi.
They are referred to as septate.
- Nonseptate or aseptate hyphae lack regularly occurring cross
walls. These cells are multinucleate and are also called
coenocytic. They often are quite variable in width with broad-
branching angles
- Hyphae may be dematiaceous (dark colored) or hyaline
(colorless).
- Fluffy surface masses of hyphae and their ‘‘hidden’’ growth
into tissue or lab medium are called mycelia.
• YEASTS are single-celled fungi, generally round to oval shaped.
They reproduce by budding (blastoconidia).
• PSEUDOHYPHAE (hyphae with sausagelike constrictions at
septations) are formed by some yeasts when they elongate but
remain attached to each other.
- Candida albicans is notable for developing into
pseudohyphae and true hyphae when it invades tissues.
• THERMALLY DIMORPHIC FUNGI are fungi capable of converting
from a yeast or yeast-like form to filamentous form and vice versa.
- Environmental conditions such as temperature and nutrient
availability trigger changes.
- Exist in the yeast or a yeastlike form in a human and as the
filamentous form in the environment. (Yeast in the heat;
mold in the cold)
- include the major pathogens:
o Sporothrix
o Blastomyces
o Histoplasma
o Coccidioides
o Paracoccidioides
• FUNGAL SPORES are formed either asexually or by a sexual process
involving nuclear fusion and then meiosis. Fungal morphology
including spores may be used in identification.
- Conidia are asexual spores of filamentous fungi (molds) or
mushrooms
- Blastoconidia are the new yeast ‘‘buds’’
- Arthroconidia are conidia formed by laying down joints in
hyphae followed by fragmentation of the hyphal strand
 Fungi require preformed organic carbon compounds (heterotrophic
nutrition) derived from their environment.
• SAPROBES / SAPROPHYTES live on dead organic material. Some
are opportunistic, causing disease if traumatically implanted into
tissue.
• COMMENSAL COLONIZERS generally live in harmony on humans,
deriving their nutrition from compounds on body surfaces. Some
are opportunists because under certain conditions (e.g., reduced
immune responsiveness) they may invade tissue or vasculature and
cause disease.
• PATHOGENS infect the healthy but cause more severe disease in
the compromised hosts. The damage to living cells provides
nutrition. Most of these are also environmental saprobes.
COMPARISON: FUNGI VERSUS BACTERIA
Feature Fungi Bacteria
Nucleus Eukaryotic Prokaryotic
Mitochondria and ER Present Absent
Cell membrane sterols Absent
Present
(except in Mycoplasma)
Cell wall content Chitin Peptidoglycan
Spores Reproduction Survival
Dimorphism Yes No
Metabolism Aerobic Aerobic or anaeroic
FUNGAL PATHOGENESIS
• Two types of host response: granulomatous or pyogenic response
• Some can be detected by using skin tests for delayed
hypersensitivity reaction
• Reduced cell immunity predisposes to disseminated disease
OVERVIEW OF FUNGAL DISEASES
A. FUNGAL ALLERGIES
• sick building syndrome
• farmer’s lung
• silo worker’s disease
• allergic bronchopulmonary aspergillosis (Aspergillus fumigatus)
B. MYCOTOXICOSES
• may result from ingestion of fungal-contaminated foods
• e.g., St. Anthony’s fire from ergot-contaminated bread or aflatoxin
[a carcinogen] -contaminated peanuts
• ingestion of psychotropic (Psilocybe) or toxic (Amanita) mushrooms.
C. FUNGAL INFECTIONS (MYCOSES)
• Mycoses range from superficial to overwhelming systemic infections
that are rapidly fatal in the compromised host.
• Mycoses are increasing in prevalence as a result of increased use of
antibiotics, corticosteroids, and cytotoxic drugs.
LABORATORY DIAGNOSIS OF FUNGI
- Microscopic examination: rapid methods
1. Potassium hydroxide in a wet mount (KOH mount) of skin scrapings
breaks down the human cells, enhancing the visibility of the
unaffected fungus
2. A nigrosin or India ink wet mount of cerebrospinal fluid (CSF)
highlights the capsule of Cryptococcus neoformans but is very
insensitive (misses 50% of cases).
3. A Giemsa or Wright’s stain of thick blood or bone marrow smear may
detect the intracellular Histoplasma capsulatum.
4. Calcofluor white stain ‘‘lights up’’ fungal elements in exudates, small
skin scales, or frozen sections under a fluorescent microscope, giving
the fungus a fluorescent blue-white appearance on a black
background.
- Histologic staining: special fungal stains for fixed tissues are necessary
because fungi are not distinguished by color with hematoxylin and eosin
(H&E) stain.
1. Gomori methenamine-silver stain: fungi are dark gray to black
2. Periodic acid-Schiff (PAS) reaction: fungi are hot pink to red.
3. Gridley fungus stain: fungi are purplish rose with a yellow background
4. Calcofluor white stain: as above
5. Immunofluorescent stains are available for some fungal pathogens
- DNA probes are now available for early detection of some systemic
pathogens.
- Cultures for fungi must be specially ordered. They use special media (e.g.,
Sabouraud’s dextrose medium), enriched media (e.g., blood agar) with
- Fungal antigen detection uses known antibodies to identify circulating
fungal antigens in a patient’s serum, CSF, or urine. Antibodies are available
for Histoplasma and Cryptococcus.
- Serologic testing
ANTIFUNGAL THERAPY
DRUGS MECHANISM OF ACTION
Polyenes Binds to ergosterol in fungal cell membranes,
- Amphotericin B forming leaky pores
Azoles Inhibit fungal P450-dependent enzymes (lanosterol
- Ketoconazole 14-a-demethylase) blocking ergosterol synthesis;
- Fluconazole resistance can occur with long-term use
- Itraconazole
- Posaconazole
- Voriconazole
Terbinafine Inhibits epoxidation of squalene
Echinocandins Inhibit β-glucan synthase decreasing fungal cell
- Caspofungin wall synthesis
- Micafungin
- Anidulafungin
Flucytosine Blocks nucleic acid synthesis by Inhibiting DNA and
RNA polymerases
Griseofulvin interferes with microtubule function in
dermatophytes and may also inhibit the synthesis
and polymerization of nucleic acids
33
 NAME RESERVOIR / TRANSMISSION
DERMATOPHYTES Depending on the particular
Trichophyton species
- Infection of skin, hair, and
nails Soil (geophilic)
Animals (zoophilic)
Microsporum Human (anthropophilic)
- Infection of skin and hair
- Not the cause of tinea Infections due to zoophilic or
unguium geophilic dermatophytes may
produce a more intense
Epidermophyton inflammatory response than
- Infection of skin and nails those caused by
- Not the cause of tinea anthropophilic microbes
capitis
Transmission: direct contact,
dogs, and cats
Malassezia furfur Naturally found on the skin
surfaces of many animals,
including humans.
Isolated in 18% of infants and inhabitant
90-100% of adults.
May be spread from person to yeast-like conidia
person, fomites
Sporothrix schenkii Found on rose thorns
MORPHOLOGY PATHOGENESIS / CLINICAL SYNDROME DIAGNOSIS TREATMENT NOTES ANATOMIC LOCATION
- Chronic infections often located in the warm, 10% KOH: branched /septate hyphae Topical imidazole Secretes the enzyme CUTANEOUS
humid areas of the body keratinase, which digests
- Inflamed circular border containing Wood’s lamp: certain species of Oral griseofuivin is used for keratin (infect only
papules and vesicles surround a clear Microsporum will fluoresce under tinea unguium and tinea superficial keratinized
area of normal skin ultraviolet light (green fluorescence) capitis structure)
- Hypersensitivity causes dermatophytid
A fungal culture using Sabouraud’s Oral terbinafine For atypical presentations
reactions (inflammatory reaction to of tinea corporis, further
dermatophytosis to a cutaneous site DISTANT from
agar: hyphae and conidia
Keep skin dry evaluation for HIV
the primary infection)
PCR infection and/or an
DERMATOPHYTOSES immunocompromised
Fungal DNA identification state should be
Tinea corporis (body): “ringworm”
considered.
Tinea cruris (groin): “jock itch”
Tinea pedis (feet): “athlete’s foot”
Tinea capitis (scalp)
Tinea unguium (nail): Onychomycosis
Tinea manum
Tinea barbae (facial hair)
A basidiomycete TINEA/PITYRIASIS VERSICOLOR KOH prep: reveals short, curved, Dandruff shampoo SUPERFICIAL (SKIN)
 usually characterized by hypopigmented or unbranched hyphae with spherical (containing selenium sulfide)
Lipophilic, skin hyperpigmented macules and patches on yeast cells (look like “spaghetti and
the chest and the back meatballs”) Topical imidazole
 In patients with a predisposition, tinea
Predominantly produce versicolor may chronically recur Fluorescence under Wood’s lamp
 fungal infection is localized to the stratum
corneum Malassezia is extremely difficult to
Infectious particles:  High temperature, humidity favour propagate in laboratory culture and is
short hyphae, yeast-like occurrence culturable only in media enriched
cells (conidia)  Degradation of lipids leads to production of with C12- to C14-sized fatty acids.
acids and eventual destruction of
melanocytes
Dimorphic SPOROTRICHOSIS KOH exam of aspirates, pus, biopsy Cutaneous form: SpROSEthrix SUBCUTANEOUS
 Gardener’s / Rose-hander’s disease materials (typically unrewarding) Potassium iodide
ROSE-hander’s disease
An ascomycete  causes local pustule or ulcer with nodules Oral itraconazole
(Ophiostoma stenoceras) along draining lymphatics (ascending Tissue smears (often negative, ROSEtte/daisy-like
lymphangitis) sensitivity enhanced by GMS, PAS, Systemic form: cluster of conidia
Soil, plant saprophyte  Occur as: FAB) Amphotericin B
- Cutaneous (lymphocutaneous) - Round-oval, cigar-shaped yeast
- Disseminated/systemic (bones, joints) cells
Infectious particles:  Follows a puncture wound (thorn prick, - Asteroid bodies (H&E)
hyphae, conidia splinter)
 frequently an occupational disease Others: direct IF, serology
Culture:
- On SDA (at room temperature):
fine, septate hyphae and
rosette/daisy-like clusters of
conidia on thin conidiophores
- On BHIA (at 37ºC): round to oval
yeast cells
34
 NAME RESERVOIR / TRANSMISSION MORPHOLOGY
Coccidioides immitis Desert areas of the Dimorphic:
southwestern United States - Mycelial (mold) forms
and northern Mexico with spores at 25oC
(soil)
Transmission: Respiratory - Spherule (not yeast)
via inhalation of forms at 37oC (tissues)
arthrospores
Spherule (much larger than RBC)
filled with endospores of
Coccidioides
Histoplasma capsulatum Endemic in Mississippi and Dimorphic:
Ohio River Valleys - Mycelial forms with
spores at 25oC
Grows in soil contaminated - Yeast forms at 37oC
with bird droppings
(Starling) or bat guano Two types of asexual
spores:
Trabeculate HISTOPLASMOSIS
Transmission: Respiratory
macroconidia: typical
via inhalation of airborne
thick walls and fingerlike
microconidia projections; Important in
lab identification
Macrophage filled with
Microconidia: smaller,
Histoplasma
thin, smooth-walled
spores; if inhaled,
transmit the infection
Blastomyces Eastern and Central US Dimorphic:
dermatitidis - Mycelial forms with
Transmission: Respiratory spores at 25oC
via inhalation of conidia - Yeast forms at 37oC
Round yeast with
broad-based bud
Blastomyces
Buds
Broadly
Broad-based budding
of Blastomyces
PATHOGENESIS / CLINICAL SYNDROME DIAGNOSIS TREATMENT NOTES ANATOMIC LOCATION
- Arthospores form spherules filled with Biopsy of affected tissue: lung Drugs-of-Choice: Common oppurtunisitc SYSTEMIC
biopsy, skin biopsy, etc. Amphotericin B infection in AIDS patients
endospores of coccidiodes
Itraconazole from the southwest The most common
- Granulomata in bones and CNS
Silver stain or KOH prep United States mode of infection of
- Dissemination in those who have defective
CMI If meningitis occurs, systemic fungi is thru
Culture on Sabouraud’s agar Fluconazole inhalation.
VALLEY FEVER
Serology
 Very common in Filipinos living in Latin Systemic mycoses are
America and Southwestern USA caused by dimorphic
Skin test
 Asymptomatic (in most persons) fungi: cold (20°C) =
 Influenza-like illness mold; heat (37°C) =
 Lung infiltrates, adenopathy, or effusions yeast. Only exception is
 Erythema nodosum (desert bumps) Coccidioides, which is
 Arthralgias (desert rheumatism) a spherule (not yeast)
 Meningitis in tissue. (USMLE)
- Inhaled microconidia develop into budding Lung biopsy Drugs-of-Choice: Can survive SYSTEMIC
Amphotericin B intracellularly within
yeast inside macrophages
Silver stain specimen Itraconazole macrophages
- Spreads to liver and spleen
- Dissemination in those who have defective Culture on Sabouraud’s agar will
If meningitis occurs,
CMI reveal hyphae at 25oC and yeast at
Fluconazole
37oC
 Asymptomatic (in most persons)
Serology
 Chronic Pneumonia: lesions calcify, which
can be seen on chest X-ray (closely mimics Skin test (test for exposure only)
PTB)
 Disseminated: can occur in almost any Urine antigen test
organ, especially in lung, spleen, or liver
 Erythema nodosum
 Tongue ulcerations in AIDS patients
BLASTOMYCOSIS Biopsy of affected tissue: lung biopsy, Drug-of-Choice: Rarest systemic fungal SYSTEMIC
 Chronic pneumonia skin biopsy, etc. Itraconazole infection.
 Ulcerated granulomas
 Verrucous skin lesions can simulate SCC Silver stain specimen For severe infections,
 Lytic bone lesions Amphotericin B
 Prostatitis Culture on Sabouraud’s agar
Serology
Skin test (test for exposure only)
Sputum specimens processed with
10% potassium hydroxide, cytology
smears, or a fungal stain
Enzyme immunoassay (EIA)
techniques on sputum, tissue, or
bronchoscopic specimens
35
 NAME
Paracoccidioides
brasiliensis
Budding yeast of
Paracoccidioides with
“captain’s wheel” formation
Candida albicans
Cryptococcus
neoformans
RESERVOIR / TRANSMISSION
Restricted to Central and
South America
Transmission: Respiratory
via inhalation of conidia
Normal flora of the skin, URT, Dimorphic:
GIT, and FGUT
Grows abundantly in soil
containing bird (especially
pigeon) droppings
Transmission: Respiratory
via inhalation of airborne
yeast cells
MORPHOLOGY PATHOGENESIS / CLINICAL SYNDROME DIAGNOSIS TREATMENT NOTES ANATOMIC LOCATION
Dimorphic: PARACOCCIDIOIDOMYCOSIS Biopsy of affected tissue; this shows Drug-of-Choice: SYSTEMIC
- Mycelial forms with  also known as the characteristic wheel-shaped Itraconazole
spores at 25oC - "Brazilian Blastomycosis," yeasts
- Yeast forms at 37oC - "South American Blastomycosis"
- "Lutz-Splendore-de Almeida Disease" Culture shows the agent.
Thick yeast of with - "Paracoccidioidal Granuloma"
multiple buds in  chronic pneumonia Serology is also used in endemic
wheel configuration  painful ulcers on mouth and nose areas.
“captain’s / mariner’s  typical patient is male 30-50 years old
wheel” formation  rarely causes disease in fertile-age women,
probably due to a protective effect of
estradiol
NORMAL HOST: Form germ tubes in serum and Oropharyngeal and CUTANEOUS or
- pseudohyphae and  Oral thrush chlamydo-spores in culture esophageal: Nystatin swish SYSTEMIC (normal host,
budding yeasts at 20OC  Vulvovaginitis → thick, white, curdlike, and swallow or opportunistic)
- germ tubes at 37OC “cottage cheese” discharge
 Skin infections → satellite lesions Skin infections: Clotrimazole
May appear as oval  Diaper rash
yeast with a single  Intertrigo Disseminated candidiasis:
bud or as  onychomycosis Amphotericin-B
pseudohyphae
IMMUNOCOMPROMISED HOST: Chemoprophylaxis:
 Pseudomembranous esophagitis Fluconazole
 Subcutaneous nodules
 Right-sided endocarditis
 Disseminated candidiasis: acquired by very
sick hospitalized patients, resulting in multi-
organ system failure
 Chronic mucocutaneous candidiasis
Oval yeast with CRYPTOCOCCOSIS India ink (clear halo) and Amphotericin B + Opportunistic Mycoses SYSTEMIC
narrow-based bud  asymptomatic lung infection mucicarmine (red inner capsule) Flucytosine followed by Predisposing Factors
surrounded by a wide  cryptococcal meningitis Fluconazole for cryptococcal - broad spectrum
polysaccharide  cryptococcal encephalitis Cryptococcal Antigen Latex meningitis antibiotic use
capsule seen in India o “soap bubble” lesions in brain Agglutination System (CALAS) of
- steroid use
 MCC of meningoencephalitis in HIV - hematologic
ink preparation the CSF detects polysaccharide
Chemoprophylaxis: - transplant recipients
capsular antigen and is more specific.
Fluconazole - systemic
Yeast form only (Not
chemotherapy
dimorphic) Fungal culture
- AIDS
36
 NAME RESERVOIR / TRANSMISSION
Aspergillius fumigatus Ubiquitous: widely distributed Exists only as molds
in nature
Aspergillius flavus
Aspergillius niger
Transmission: Respiratory
via inhalation of airborne
conidia
Rhizopus Saprophytic molds
Rhizomucor
Mucor
Pneumocystis jirovecii Unicellular fungi found in the
respiratory tracts of many
mammals and humans
Pneumocystis carinii
(former name)
Transmission: Respiratory
via inhalation of cysts
MORPHOLOGY PATHOGENESIS / CLINICAL SYNDROME DIAGNOSIS TREATMENT NOTES ANATOMIC LOCATION
Aspergillus may cause a broad spectrum of disease in Allergic brochopulmonary Allergic bronchopulmonary Rarely found in OPPORTUNISTIC
(not dimorphic) the human host, ranging from hypersensitivity aspergillosis: aspergillosis: treat with individuals who are
reactions to direct angioinvasion
- High level of IgE (IgE level > 1000 corticosteroids immunocompetent
Septate hyphae that ALLERGIC BRONCHOPULMONARY IU/dL)
form V-shaped ASPERGILLOSIS - Sputum culture Aspergilloma: removal via The FDA has approved an
(dichotomous)  IgE-mediated - Wheezing patient and chest X-ray thoracic surgery intravenous formulation
 Asthma-type reaction with shortness of with fleeting infiltrates of the triazole antifungal
branches (acute
breath, high fever, and expectoration of - Increased level of eosinophils Invasive aspergillosis: treat posaconazole (Noxafil),
angles, 45O) brownish bronchial plugs - Skin test: immediate with voriconazole, possibly which is indicated for the
ASPERGILLOMA hypersensitivity reaction prophylaxis of invasive
Aspergillus: Acute Angles caspofungin (very high
 Fungus ball mortality) Aspergillus and Candida
 associated with hemoptysis Aspergilloma: diagnose with chest X- infections in severely
 Monod sign: air around aspergilloma ray or CT scan immunocompromised
INVASIVE ASPERGILLOSIS adults who are at high
Invasive aspergillosis: sputum risk of developing these
 necrotizing pneumonia
examination and culture infections.
 may disseminate to other organs in
immune-compromised patients
Aflatoxins contaminate
 (+) air crescent sign on radiography
peanuts, grains, and rice
AFLATOXIN CONSUMPTION
 produced by Aspergillus flavus
 can cause liver damage and liver cancer
INFECTIONS: wounds, burns, cornea, external
ear, sinuses
Broad, non-septated, MUCORMYCOSIS Biopsy Amphotericin B The disease is rapidly OPPORTUNISTIC
branching hyphae (right  Causes disease mostly in ketoacidotic Black nasal discharge fatal
angles, 90o) diabetic and/or neutropenic patients (eg, Surgery
leukemia)
 fungi proliferate in blood vessel walls,
penetrate cribriform plate, and enter
brain
 Rhino-orbito-cerebral infection, frontal
lobe abscess; cavernous sinus thrombosis
 Headache, facial pain, black necrotic
eschar on face; may have cranial nerve
involvement
Indeterminate organism PNEUMOCYSTIS JIROVECII PNEUMONIA Diagnosis by staining BAL washings Treatment/prophylaxis: The taxonomic classification of the Pneumocystis
 Occurs when CD4 <200  Toluidine blue TMP-SMX (DOC) genus was debated for some time. It was initially
Disc-shaped yeast mistaken for a trypanosome and then later for a
 Most common AIDS-defining illness  Methenanime silver stain
Major surface  Cysts in the alveoli induce an inflammatory For sulfa allergy: protozoan. In the 1980s, biochemical analysis of the
glycoprotein undergoes response consisting plasma cells → frothy Elevated LDH >220 U/L in patients Pentamidine nucleic acid composition of Pneumocystis rRNA and
Dapsone (prophylaxis only) mitochondrial DNA identified the organism as a
programmed exudate that blocks oxygen exchange with PCP
rearrangements  Diffuse interstitial pneumonia with Atovaquone unicellular fungus rather than a protozoan.
Quantitative PCR for pneumocystis Subsequent genomic sequence analysis of multiple
bilateral ground glass infiltrates
 100% mortality if untreated may become useful in distinguishing Start prophylaxis when CD4+ genes including elongation factor 3, a component
Morphologic stages:
between colonization and active count drops to < 200 of fungi protein synthesis not found in protozoa,
Trophozoite (trophic
form): often exists in infection. cells/mm3 in HIV patients. further supported this notion.
clusters
Sporozoite (precystic
form)
Cyst: contains several
intracystic bodies (spores)
37
MEDICAL VIROLOGY P. CALDERON, E. CALDERON JR., REÑA
VIRAL STRUCTURE
• Range in size from 20 – 300 nm
• All viruses have a protein coat (capsid)
o Composed of repeating capsomers (building blocks of capsid)
o In some viruses, covered with lipoprotein envelope
o Two types of capsid: icosahedral and helical
• Nucleic acid genome + capsid = nucleocapsid
VIRAL SYMMETRY
• Symmetry: spherical (icosahedral) or helical
• All helical viruses are enveloped
• Icosahedral viruses can be enveloped or naked
o All DNA viruses are icosahedral except Poxvirus
• Only RNA viruses have helical symmetry
o Most assume a spherical shape except rhabdoviruses,
which have a bullet-shaped capsid.
o Most RNA viruses have helical symmetry except:
▪ Flaviviruses
▪ Caliciviruses
▪ Reoviruses RNA viruses with
▪ Picornavirus icosahedral symmetry
▪ Togaviruses
▪ Hepevirus
VIRAL PROTEINS
• Surface proteins: attachment to host cell receptors
• DNA or RNA polymerases
• Matrix protein: interaction between nucleocapsid and
envelope
• Antigenic (serotypic) variants: evasion of host defenses
VIRAL ENVELOPE
• Lipid membrane derived from the host cells
o Acquired as the virus exits from the cell in a process called
budding
o All enveloped viruses acquire their envelope from plasma
membrane EXCEPT Herpes virus (from nuclear
membrane)
• Enveloped viruses are less stable and more easily inactivated
NAKED VIRUSES: Viruses that do not have membranes
Give PAPP smears and CPR to a naked hippie (hepevirus).
Naked DNA Virus Naked RNA Virus
Papillomavirus Calicivirus
Adenovirus Picornavirus
Parvovirus Reovirus
Polyomavirus Hepevirus
NAKED VIRAL GENOME INFECTIVITY
• Purified nucleic acids of most dsDNA (EXCEPT poxviruses and
HBV) and (+) strand genome ssRNA viruses are infectious
• Naked nucleic acids of (-) strand ssRNA and dsRNA viruses are
not infectious
o Require polymerases contained in the complete virion
PRIONS
• Infectious particles composed entirely of proteins which cause
transmissible spongiform encephalopathies
o Nonpathogenic as alpha-helix
o Pathogenic as beta-pleated sheet
• Highly resistant to inactivation
• Do not elicit an inflammatory response or an antibody response
VIRAL GENOME
• ALL viruses are haploid EXCEPT retroviruses
• Contain either DNA or RNA, but not both
• Genomes can either be single-stranded or double-stranded
• Genomes of RNA viruses can either positive-polarity or
negative polarity
• Some RNA viruses have segmented genome
SEGMENTED GENOME
Bunyaviruses
Orthomyxoviruses (influenza)
Arenaviruses
Reoviruses
RNA VIRUSES
• Two types of RNA viruses: positive-stranded or negative-
stranded
• POSITIVE-STRANDED RNA VIRUSES
o RNA is just like a messenger RNA (mRNA)
o When a positive-stranded RNA virus enters a host cell, its
RNA can immediately translated by the host’s ribosomes
into protein
• NEGATIVE-STRANDED RNA VIRUSES
o When negative-stranded RNA viruses enter the cell, they
are not able to begin translation immediately
o Must transcribe negative strand to positive (–) → (+)
o Virion brings its own RNA-dependent polymerase, which
will carry out the transcription of the negative-strand into
positive.
NEGATIVE-STRAND RNA VIRUSES
Always Bring Polymerase Or Fail Replication
Arenaviruses
Bunyaviruses
Paramyxoviruses (Measles, Mumps, RSV, Parainfluenza)
Orthomyxoviruses (Influenza A&B)
Filoviruses (Ebola)
Rhabdoviruses (Rabies)
• RETROVIRUSES are unique because of their ability to
incorporate into the host genome.
• REOVIRIDAE (including ROTAVIRUS) are the only RNA viruses
with a double-stranded RNA genome
DNA VIRUSES
• Unlike RNA, DNA cannot be translated directly into proteins.
• It must be transcribed into mRNA with subsequent translation
of mRNA into structural proteins and enzymes
• Most DNA viruses have both a negative strand and a positive
strand except PARVOVIRUSES, which have single-stranded
DNA genome
• All double-stranded DNA have icosahedral symmetry except
POXVIRUS in which DNA has complex structural proteins
looking much like a box.
• Negative strand refers to the DNA strand that is read; used as
a template for transcription into mRNA,
• Positive strand is ignored.
38
VIRAL GENETICS
• Mutations can produce antigenic, drug-resistant, or LABORATORY DIAGNOSIS
attenuated variants
PRESUMPTIVE IDENTIFICATION
• Recombination: exchange of genes between 2 chromosomes
• Cytopathic effect
by crossing over within regions of significant base sequence
• Hemadsorption: attachment of RBCs to surface of infected cells
homology
• Interference: interference with CPE by another virus
• Genetic reassortment: when viruses with segmented genomes
• Decrease in acid production by infected, dying cells (using
exchange genetic material; causes epidemics
phenol red)
o Example: influenza viruses
• Complementation: one virus produces a protein that can be
DEFINITIVE DIAGNOSIS
used by another virus
• Complement fixation
o Example: Hepatitis D and Hepatitis B
• Hemagglutination inhibition
• Phenotype mixing: two different viruses infect the same cell
• Neutralization
• Fluorescent antibody assay
VIRAL GROWTH CURVE
• Radioimmunoassay
• Enzyme-linked immunosorbent assay (ELISA)

SEROLOGIC TESTS
• Seroconversion: finding antibody in one who previously had
none
• Presence of IgM: can be used to diagnose current infection
• Presence of IgG: cannot be used to diagnose current infection;
antibody may be due to an infection in the past

DETECTION OF VIRAL ANTIGENS

• Presence of viral proteins, commonly used in diagnosis
• Example: p24 of HIV and HbSAg
• Presence of viral DNA or RNA is the gold standard in viral
diagnosis

Phase 0 Entry A single virus infects a cell VIRAL VACCINES

Phase 1 Decline Virus decreases in number but LIVE-ATTENUATED VACCINES
continue to function • Induce humoral and cell-mediated immunity but may revert to
Phase 2 Eclipse Period No virus is detectable inside the cell virulence on rare occasions
• Dangerous to give to immunocompromised patients or their
Phase 3 Rise Period Dramatic increase in amount of close contacts
detectable viruses
• Examples: (MISS CRY)
Phase 4 Latent Amount of detectable viruses reaches a o MMR (the only live-attenuated vaccine that can be given
plateau to HIV-positive patients who do not show signs of
immunodeficiency)
Phase 5 Cytopathic Marked derangement of cell function
o Influenza (intranasal)
Effect leading to lysis and cell death
o Smallpox
Remarkable amplification in number of
o Sabin’s polio vaccine
viral particles
o Chicken pox
o Rotavirus
OUTCOMES OF VIRAL INFECTION o Yellow fever
Cytopathic effect Visual or functional change in infected cells
Hallmark of viral infection of cell KILLED VACCINES
Malignant Oncogenic viruses induce transformation and • Induce only humoral immunity but are stable
• Examples: (RIP Always; SalK=Killed)
transformation unrestrained growth
o Rabies
Commensal Infected cells appear normal, but are o Influenza (injected)
symbiosis producing large numbers of progeny viruses o Salk’s Polio vaccine
o Hepatitis A
VIRULENCE FACTORS
Cytokines decoys Bind cytokines and block their ability to RECOMBINANT VACCINES
interact with receptors on their intended • Examples:
targets o Hepatitis B (recombinant HBsAg)
o HPV (Types 6, 11, 16, 18)
Virokines Reduce the expression of antigen presenting
cells and inactive complement RECEPTORS USED BY VIRUSES
Antigenic variants of surface proteins
Virus Receptors
PERSISTENT VITAL INFECTIONS CMV Integrins (heparan sulfate)
Carrier state Produce virus for long periods of time EBV CD21
Can serve as a source of infection to others
HIV CD4, CXCR4, CCR5
Latent infections Not producing virus at the present but can
Parvovirus B19 P antigen on RBCs
be reactivated at a subsequent time
Rabies Nicotinic AChR
Slow virus infections Long incubation period, often measured in
years Rhinovirus ICAM-1

39
CLINICAL FEATURES OF DNA NAKED VIRUSES

IMPORTANT FEATURES OF COMMON HERPESVIRUS INFECTIONS

40
CHARACTERISTICS OF VIRUSES ANTIVIRAL DRUGS
DNA or RNA? DNA viruses are HHAPPPPy The rest are RNA.
Hepadna
Herpes
Adeno
Pox
Parvo
Papilloma
Polyoma
Enveloped or Naked DNA Virus Naked RNA Virus
Naked? Papillomavirus Calicivirus
Adenovirus Picornavirus
Parvovirus Reovirus
Polyomavirus Hepevirus
Symmetry All DNA viruses are icosahedral Most RNA viruses have helical symmetry
except Poxvirus → complex except the following which are icosahedral:
▪ Flavi
▪ Calici
▪ Reo (Rota)
▪ Picorna
▪ Toga
▪ Hepe
If RNA, segmented SEGMENTED GENOME
or non-segmented Bunyaviruses
(one-piece)? Orthomyxoviruses (influenza)
Arenaviruses
Reoviruses (Rotavirus)
Double stranded or All DNA viruses have double- All RNA viruses have single-stranded RNA
Single-stranded? stranded DNA EXCEPT: Reovirus (Rotavirus) → dsRNA
EXCEPT: Parvovirus → ssDNA
If ssRNA, positive NEGATIVE-STRAND RNA VIRUSES
sense or negative Always Bring Polymerase Or Fail Replication
sense? Arenaviruses
Bunyaviruses
Paramyxoviruses (Measles, Mumps, RSV, Parainfluenza)
Orthomyxoviruses (Influenza A&B)
Filoviruses (Ebola)
Rhabdoviruses (Rabies)
Site of replication All DNA viruses replicate in the All RNA viruses have replicate in the cytoplasm
nucleus EXCEPT: INFLUENZA VIRUS
EXCEPT: POXVIRUS → cytoplasm RETROVIRUSES

41
 DNA VIRUSES RNA VIRUSES

HHAPPPPy DNA Viruses: Hepadna, Herpes, Adeno, Pox, Parvo, Papilloma, Polyoma
All DNA viruses have double stranded DNA EXCEPT: PARVOVIRUS (single-stranded) All RNA viruses have single stranded RNA EXCEPT: REOVIRUS (ROTAVIRUS) (dsRNA)
All DNA viruses have linear DNA EXCEPT: PAPILLOMAVIRUS (circular, supercoiled) All RNA viruses have replicate in the cytoplasm EXCEPT: INFLUENZA VIRUS
POLYOMAVIRUS (circular, supercoiled) RETROVIRUSES
HEPADNAVIRUS (circular, incomplete)
All DNA viruses are icosahedral EXCEPT: POXVIRUS (complex)
All DNA viruses replicate in the nucleus EXCEPT: POXVIRUS (cytoplasm; carries own DNA-dependent RNA
polymerase)

42
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43
 VIRUS MORPOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
NAKED DNA VIRUSES
PARVOVIRIDAE: The smallest DNA virus; the only DNA virus that is single-stranded.
Parvovirus B-19 Naked icosahedral Respiratory Droplets ERYTHEMA INFECTIOSUM (FIFTH DISEASE) Illness is self-limited RBC destruction in fetus
 affects children between the ages of 4 to 12 leads to hydrops fetalis and
Single-stranded linear DNA Transplacental  bright red cheek rash (“Slapped cheek”) with fever, coryza, and sore I.V. immunoglobulin can be used death, in adults leads to
virus (negative stranded) throat with aplastic crisis pure RBC aplasia and
rheumatoid arthritis–like
APLASTIC CRISIS:
One serotype symptoms
 Transient but severe aplastic anemia in children with sickle cell anemia,
thalassemia, or spherocytosis
 occurs when the Parvovirus stops the production of red blood cells in the
bone marrow
FETAL INFECTIONS
 First trimester: Fetal death
 Second trimester: Hydrops Fetalis
ARTHRITIS
 Immune-complex arthritis of small joints
CHRONIC B-19 INFECTION
 pancytopenia in immunodeficient patients

ADENOVIRIDAE
Adenovirus Naked icosahedral Aerosol droplet URT: Pharyngitis, conjunctivitis, coryza Histopathology: Illness is self-limited
Double-stranded linear DNA LRT: bronchitis, atypical pneumonia Cowdry type B intranuclear
41 serotype Fecal-oral GIT: acute gastroenteritis basophilic inclusion bodies
GUT: acute hemorrhagic cystitis
Direct contact
PAPOVAVIRIDAE: The second smallest DNA virus
Human Naked icosahedral Direct contact - Infect squamous cells and induce formation of cytoplasmic vacuole Genital warts: Podophyllin Koilocytes: small, round,
Papillomavirus Double-stranded circular (koilocytes) deeply basophilic nuclei
DNA Sexually - Genes E6 and E7: encode proteins that inactivate tumor suppressor Skin warts: Liquid nitrogen surrounded by a clear
At least 100 types genes. E6 inhibits p53; E7 inhibits Rb halo and pale-staining
- Genes E1 and E2: promote viral DNA replication Plantar warts: Salicylic acid cytoplasm

HPV 1, 2, 4, 7 Skin and plantar warts, verruca vulgaris PREVENTION:

HPV 6 and 11 Genital warts (condyloma acuminata) Vaccine for HPV 6, 11, 16, and
Respiratory tract papillomas 18 for females 9-26 years old
Most common viral STD
HPV 16, 18, 31, 33 Carcinoma of the cervix, vulva, penis, anus

JC Polyoma Virus Naked icosahedral - Only causes disease in immunocompromised hosts JC: Junky Cerebrum
(John Cunningham virus) Double-stranded circular - Causes progressive multifocal leukoencephalopathy in patients
DNA with AIDS
 Demyelinating disease that affects the oligodendrocytes
characterized by deficits in speech, coordination, and memory

BK Polyoma Virus Naked icosahedral - causes disease in immunocompromised hosts BKV blood test or a urine test BK: Bladder, Kidney
Double-stranded circular - causes hemorrhagic cystitis and nephropathy in patients with solid for decoy cells
DNA organ (kidney) and bone marrow transplants Biopsy of the kidneys
PCR techniques

44
 VIRUS MORPOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
ENVELOPED DNA VIRUSES
HERPESVIRIDAE
Herpes Simplex Enveloped icosahedral HSV 1: saliva or - Vesicle filled with virus particles and cell debris Tzanck smear: Drug-of-choice: HSV-1 is the most
Double-stranded linear DNA direct HSV-1 (HHV-1) HSV-2 (HHV-2) multinucleated giant cells Acyclovir common cause of sporadic,
Viruses (HSV)
Gingivostomatitis Genital herpes - Shortens duration of the fatal encephalitis in the
HSV 2: sexual or Herpes labialis (lips) Neonatal herpes (TORCH) Large, pink to purple Cowdry lesions USA
transvaginal Keratoconjunctivitis Aseptic meningitis Type A eosinophilic - Reduces the extent of
shedding of the virus TEMPORAL LOBE:
Temporal lobe encephalitis intranuclear inclusions
- No effect on the latent state principal target area of the
Herpetic whitlow (fingers)
virus
Herpes gladiatorum (trunk)
Site of Latency CSF-PCR for herpes
Trigeminal ganglia Lumbosacral ganglia encephalitis

Varicella-Zoster Virus Enveloped icosahedral Airborne-droplet - Infects the URT, then spreads via the blood to the skin HP: multinucleated giant cells Mild: NO TREATMENT USES OF ASPIRIN IN
Double-stranded linear DNA - Becomes latent in the dorsal root ganglia, which may reactivate as with intranuclear inclusions
(VZV) / HHV-3 PEDIATRIC DISEASES:
Direct contact with zoster Moderate to Severe:
the lesions - Kawasaki
Large, pink to purple Cowdry Acyclovir
VARICELLA / CHICKEN POX - Shortens duration of the - ARF
Type A eosinophilic
 Incubation period: 14-21 days lesions - JRA
intranuclear inclusions
 Period of communicability: 48 hours before vesicle formation and 4-5 - Most effective if given within
days after until all vesicles are crusted 24 hours of the onset of rash
 Vesicular rash (‘dewdrop on a rose petal appearance’) that begins on
trunk; spreads to face and extremities (centrifugal) with lesions of Ramsay-Hunt Syndrome:
different stages Valacyclovir
 Complications: Pneumonia, Encephalitis, Reye’s syndrome, Prednisone
Cerebellar ataxia, secondary bacterial infection
POSTEXPOSURE PROPHYLAXIS:
HERPES ZOSTER / SHINGLES Active vaccine can be given
 Unilateral painful vesicular eruption with a dermatomal distribution within 5 days of exposure to
(thoracic and lumbar) modify course
 Debilitating pain (postherpetic neuralgia) → most common complication Anti-VZV Ig: given within 96h
after exposure; for pregnant,
RAMSAY-HUNT SYNDROME / HERPES ZOSTER OTICUS
newborns exposed to maternal
 Reactivation of latent VZV residing within geniculate ganglion
varicella, and
 A triad of ipsilateral facial paralysis, ear pain, and vesicles on the face, on
immunocompromised
the ear, or in the ear is the typical presentation.

CONGENITAL VARICELLA
 Fetuses infected at 6-12 weeks’ AOG: maximal interruption with limb
development (short and malformed limbs covered with cicatrix – skin
lesion with zigzag scarring associated with atrophy of the affected limb)
 Fetuses infected at 16-20 weeks’ AOG: eye and brain involvement

45
 VIRUS MORPOGY
Cytomegalovirus Enveloped icosahedral
(CMV) / HHV-5 Double-stranded linear DNA
Epstein-Barr Virus Enveloped icosahedral
Double-stranded linear DNA
(EBV) / HHV-4
Human Herpesvirus 6 Enveloped icosahedral
Double-stranded linear DNA
(HHV-6)
Human Herpesvirus 8 Enveloped icosahedral
Double-stranded linear DNA
(HHV-8)
POXVIRIDAE: Largest DNA virus; the only DNA virus that is complex (not icosahedral); the only DNA virus that replicates in the cytoplasm (not in the nucleus)
Variola virus Enveloped complex Aerosol
Brick-shaped poxvirus
containing linear double-
stranded DNA
Replicates in the cytoplasm
Molluscum
Contagiosum virus
TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
Human body fluids - Immediate early proteins Cultured in shell tubes Drug-of-Choice: owl’s-eye nuclear inclusion
o Translated from premade mRNAs Ganciclovir Perientricular
Transplacental o Impair assembly of the MHC class 1-viral peptide complexes Negative heterophil test - CMV is largely resistant to Calcification is seen
CONGENITAL CMV INFECTION acyclovir
Organ
Cytomegaloirus
 Most common infectious cause of congenital abnormalities Giant cells with owl’s-eye
transplantation  Most common intrauterine viral infection DOC for prevention of CMV disease
 Most common when the mother is infected in first trimester
nuclear inclusion in solid-organ transplant patients is
 Microcephaly, seizures, deafness, jaundice, and purpura valganciclovir
 Periventricular calcifications
HETEROPHIL-NEGATIVE MONONUCLEOSIS
 Fever, lethargy, and abnormal lymphocytes in blood smears
SYSTEMIC CMV INFECTIONS
 Pneumonitis, hepatitis, colitis
 AIDS retinitis: hemorrhage, cotton-wool exudates, vision loss
Saliva - Infects mainly lymphoid cells, primarily B-lymphocytes through CD21 Differential white blood cells MONONUCLEOSIS
- Elicits EBV-specific antibodies and non-specific count will show elevated
“atypical lymphocytes” → Heterophil-Positive:
INFECTIOUS MONONUCLEOSIS Downey cells  Epstein-Barr Virus
 ‘Kissing disease’
 Monospot-positive/heterophil-positivefever, sorethroat, Heterophil-Negative:
lymphadenopathy
 splenomegaly → rapid increase in size produces a tense, fragile, splenic
capsule → splenic rupture is a rare complication (Avoid contact sports!)
Use of amoxicillin in
MALIGNANCIES mononucleosis can cause
 Burkitt’s lymphoma (in African people) characteristic
 B-cell lymphomas maculopapular rash.
 Nasopharyngeal carcinoma (in Chinese people)
 Hairy leukoplakia (in AIDS patients)
saliva ROSEOLA / EXANTHEM SUBITUM / SIXTH DISEASE
- rose-colored macules appear on body after several days of high fever;
can present with febrile seizures; usually affects infants
- Nagayama spots: erythematous papules on soft palate and base of the uvula
Sexual KAPOSI SARCOMA Surgical excision
 most common AIDS-related malignancy Radiation
Organ  malignancy of the vascular endothelial cells
transplantation  Dark/violaceous plaques or nodules representing vascular proliferations
SMALLPOX HP: Guarnieri bodies:
 Only disease that has been eradicated from the face of the earth intracytoplasmic
Contact  Incubation Period: 7 – 14 days
eosinophilic inclusions
 Prodrome of fever and malaise followed by centrifugal rash
 Classic smallpox lesions: deep-seated, firm/hard, round well-circumscribed
vesicles or pustules; as they evolve, lesions may become umbilicated or
confluent Guarnieri bodies
 Lesions with same stage of development
Direct contact MOLLUSCUM CONTAGIOSUM HP: Henderson-Patterson Cifodovir
 flesh-colored dome-shaped papules with central umbilication bodies: intracytoplasmic
eosinophilic inclusions
46
 VIRUS MORPOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
HEPADNAVIRIDAE
Hepatitis B Virus Enveloped virus with Blood transfusion - the only DNA virus that produces DNA by reverse transcription with Acute diagnosis: Entecavir The virus is one of the
incomplete circular double- mRNA as the template; not a retrovirus but has reverse transcriptase HBsAg, IgM anti-HBc smallest enveloped animal
Tenofovir
stranded DNA Needlestick injury - hepatocellular injury due to immune attack by cytotoxic T cells viruses, and the 42 nm
Interferon-alpha virions, which are capable of
➢ HBV has no cytopathic effect Chronic diagnosis:
Sexual Lamivudine infecting hepatocytes, are
HBsAg, IgG anti-HBc
VIRULENCE FACTORS: referred to as "Dane
Across the placenta  Surface antigen (HBsAg) Markers of replication: PREVENTION: particles" → the complete
 Core antigen (HBcAg) HBeAg, HBV DNA HEPATITIS B VACCINE infectious form of Hepatitis
Perinatally  e antigen (HBeAg): used as marker of potential infectivity - First vaccine to prevent a B virus
Liver Biopsy: Granular human cancer
HEPATITIS B INFECTION eosinophilic “ground - 1st dose should be given first
 Incubation Period: 10-12 weeks 12 hours of life and counted Age at the time of
 Fever, anorexia, and jaundice glass” appearance
as part of 3-dose primary infection is the best
 Dark urine, pale feces, and elevate transaminase levels series
 Can lead to cirrhosis and hepatocellular carcinoma predictor of chronicity.
- Subsequent doses are given at
 Extrahepatic manifestations: Councilman body: least 4 weeks apart
The younger the age at the
eosinophilic globule of cells time of HBV infection, the
o Aplastic Anemia - 3rd dose preferably given >24
that represents a dying higher the probability of
o Membranous → Membranoproliferative glomerulonephritis weeks of age chronicity.
hepatocyte often surrounded
o Polyarteritis nodosa (autoimmune vasculitis) by normal parenchyma

SEROLOGIC EVOLUTION INTERPRETATION OF SEROLOGY Complications:

Time Period HBsAg Anti-HBs Anti-HBc HBeAg HEPATORENAL SYNDROME: functional renal failure without renal
Incubation Period (+) (-) (-) (+) pathology
Acute Infection (+) (-) (+) IgM (+)
Window Period (-) (-) (+) IgM (-) HEPATOPULMONARY SYNDROME: vascular dilatations cause
Complete Recovery (-) (+) (+) IgG (-) overperfusion relative to ventilation, leading to V/Q mismatch and
Chronic Carrier (+) (-) (+) IgG (-) hypoxemia
Chronic Active (+) (-) (+) IgG (+)
Vaccinated (-) (+) (-) (-) PORTAL HYPERTENSION

HEPATIC ENCEPHALOPATHY
The only positive during window period: Anti-HBc IgM
The only positive among vaccinated patients: Anti-HBs
What can differentiate chronic active infection from chronic carrier: HBeAg

Chronic infection is characterized by the persistence of HBsAg for at least 6

months.

Persistence of HBsAg is the principal marker of risk for developing chronic

liver disease and liver cancer (hepatocellular carcinoma) later in life.

47
 DNA VIRUSES RNA VIRUSES

HHAPPPPy DNA Viruses: Hepadna, Herpes, Adeno, Pox, Parvo, Papilloma, Polyoma
All DNA viruses have double stranded DNA EXCEPT: PARVOVIRUS (single-stranded) All RNA viruses have single stranded RNA EXCEPT: REOVIRUS (ROTAVIRUS) (dsRNA)
All DNA viruses have linear DNA EXCEPT: PAPILLOMAVIRUS (circular, supercoiled) All RNA viruses have replicate in the cytoplasm EXCEPT: INFLUENZA VIRUS
POLYOMAVIRUS (circular, supercoiled) RETROVIRUSES
HEPADNAVIRUS (circular, incomplete)
All DNA viruses are icosahedral EXCEPT: POXVIRUS (complex)
All DNA viruses replicate in the nucleus EXCEPT: POXVIRUS (cytoplasm; carries own DNA-dependent RNA
polymerase)

48
 VIRUS MORPHOLOGY
PICORNAVIRIDAE
Poliovirus Naked (+) ssRNA
Naked icosahedral symmetry
Three serologic (antigenic)
types based on different
antigenic determinants on the
outer capsid proteins
TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
NAKED RNA VIRUSES
Oral-fecal - replicates in motor neurons in anterior horn of spinal cord, causing HP: Cowdry type B PREVENTION: ENTEROVIRUSES
paralysis intranuclear inclusions Vaccination
- host range is limited to primates
- Poliovirus
SALK SABIN
- Limitation is due to the binding of the viral capsid to a receptor found IPV OPV - Echovirus
only on primate cell membrane - Coxsackie virus
Killed Live, attenuated
POLIOMYELITIS AND MENINGITIS RNA viruses with
 Inapparent, asymptomatic infection The oral vaccine or Sabin vaccine icosahedral symmetry
 Abortive poliomyelitis which is a live attenuated vaccine ▪ Flaviviruses
- Most common clinical form is preferred over the Salk vaccine ▪ Caliciviruses
- Mild febrile illness with headache, sore throat, nausea, and vomiting or killed vaccine because it ▪ Reoviruses
 Non-paralytic poliomyelitis interrupts fecal-oral transmission ▪ Picornavirus
- Aseptic meningitis by inducing secretory IgA in the
 Paralytic poliomyelitis ▪ Togaviruses
GIT; killed vaccine does not.
- Flaccid paralysis, permanent nerve damage ▪ Hepevirus

Coxsackie virus Naked (+) ssRNA
Classification is based on
pathology in mice
Oral-fecal Coxsackie A viruses
 Herpangina (vesicular pharyngitis)
 Acute hemorrhagic conjunctivitis
 Hand-foot-and-mouth disease
(vesicular rash on hands and feet
and ulcerations in the mouth)
 Aseptic meningitis
Coxsackie B viruses NOTE:
 Pleurodynia (Bornholm disease, Pleurodynia is pain due to
“devil’s grip”) an infection of the
 Severe generalized disease of intercostal muscles
infants (myositis), not of the pleura.
 Myocarditis, pericarditis (Most
commonly identified causative
agent of heart disease in humans)
 Aseptic meningitis

ECHO virus Naked (+) ssRNA Oral-fecal ASSOCIATED DISEASES: Orphan virus means a
(Enteric Cytopathic  Aseptic meningitis virus that is not associated
 Upper respiratory tract infection with any known disease.
Human Orphan)  Febrile illness with and without rash Even though Echoviruses have
 Infantile diarrhea since been identified with
various diseases, the original
 Hemorrhagic conjunctivitis name is still used.

Rhinovirus Naked (+) ssRNA Aerosol droplets - replicate better at 33°C than at 37°C → affect primarily the nose and Common cold: most
conjunctiva rather than the lower respiratory tract common human infection
More than 100 serotypes Hand-to-nose - acid-labile → they are killed by gastric acid when swallowed → do not
contact infect the GIT (unlike the enteroviruses)
- Host range is limited to humans and chimpanzees

Hepatitis A virus Naked (+) ssRNA Oral-fecal - The virus replicates in the GI tract and then spreads to the liver during a Anti-HAV IgM: most useful PREVENTION: There is no antigenic
brief viremic period. test to diagnose acute Vaccine contains killed virus. relationship between
(aka Enterovirus 72)
Virus has a single serotype - The virus is not cytopathic for the hepatocyte. infection Hepatitis A and other
- Hepatocellular injury is caused by immune attack by cytotoxic T cells. Administration of immune hepatitis viruses.
globulin during the incubation
HEPATITIS A INFECTION period can mitigate the disease
 Children most frequently infected
 Self-limited hepatitis
 Short incubation hepatitis
 Anicteric hepatitis: asymptomatic or only mildly ill, absence of jaundice,
with positive serologic evidence of infection

49
 VIRUS MORPHOLOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
HEPEVIRIDAE
Hepatitis E virus Naked icosahedral (+) ssRNA Oral-fecal  Causes outbreaks of hepatitis (epidemics), primarily in developing Liver Biopsy: Hepatitis E
countries Patchy necrosis - Expectant (pregnant)
 no chronic carrier state, no cirrhosis, and no hepatocellular mother
carcinoma􀂙 - Enteric
 Infection is frequently subclinical
- Epidemic
 Fulminant hepatitis in pregnant women

CALICIVIRIDAE
Norwalk virus Naked icosahedral (+) ssRNA Oral-fecal VIRAL GASTROENTERITIS RNA viruses with
(Norovirus)  Most important cause of epidemic viral (nonbacterial) gastroenteritis icosahedral symmetry
in adults ▪ Flaviviruses
 Sudden onset of vomiting, diarrhea, accompanied by fever and abdominal ▪ Caliciviruses
cramping ▪ Reoviruses
▪ Picornavirus
▪ Togaviruses
▪ Hepevirus
REOVIRIDAE: only RNA virus with a double-stranded RNA (dsRNA) genome
Rotavirus Naked double-layered capsid - Rotavirus is resistant to stomach acid and hence can reach the small ROTAVIRUS VACCINE SEGMENTED GENOME
with segmented double- intestine  1st dose: 6 weeks of age Bunyaviruses
stranded RNA (10 or 11 - Villous destruction with atrophy →  absorption of Na+ and loss of K+  Last dose: not later than 32
weeks of age Orthomyxoviruses
segments) VIRAL GASTROENTERITIS
 Monovalent (RV1)/Rotarix: 2- (influenza)
 Most common cause of childhood diarrhea
 Severe cases: stools are clear (“white stool diarrhea”)
dose series Arenaviruses
 Pentavalent (RV5)/RotaTeq: 3-
Reoviruses
dose series
 Min interval: 4 weeks

To God be the Greatest Glory!

50
 VIRUS MORPHOLOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
ENVELOPED RNA VIRUSES (NEGATIVE SENSE)
ORTHOMYXOVIRIDAE
Influenza Virus Enveloped virus with a helical Respiratory droplets Influenza A worldwide epidemics (pandemics) Oseltamivir (DOC) Antigenic Shift vs
nucleocapsid and segmented, each year, influenza is the MCC of respiratory and Zanamivir Antigenic Drift
ss-negative RNA infections Sudden Shift is more deadly
 used for both the treatment
has 16 antigenically distinct types of hemagglutinin and prevention of influenza than GraDual Drift
and 9 antigenically distinct types of neuraminidase; Shifts cause PANDEMICS
 neuraminidase inhibitors,
some of these types cause disease in humans but most of Drifts cause EPIDEMICS
which act by inhibiting the
the types typically cause disease in other animal species
- Many species of animals (e.g., aquatic birds, release of virus from infected
such as birds, horses, and pigs
chickens, swine, and horses) have their own cells
Influenza B Major outbreaks of influenza A for Amantadine
influenza A viruses.  effective against both influenza
Does NOT lead to pandemic effective only against
- These animal viruses are the source of the RNA A and B viruses
Influenza C Mild respiratory tract infection Influenza A
segments that encode the antigenic shift variants
Does NOT cause outbreaks of influenza
that cause epidemics among humans. Amantadine and Rimantadine
▪ E.g., if an avian and a human influenza A virus The envelope is covered with two different types of spikes (which are also
considered as the virus’ major antigens):  effective only against influenza
infect the same cell (e.g., in a farmer’s A NEGATIVE-STRAND
respiratory tract) →reassortment →new variant o HEMAGGLUTININ  no longer used due to RNA VIRUSES
of the human A virus, bearing the avian virus • bind to the cell surface receptor (neuraminic acid, sialic acid) to
widespread resistance Always Bring Polymerase
hemagglutinin, may appear initiate infection of the cell
• the target of neutralizing antibody Or Fail Replication
- There is evidence that aquatic birds (waterfowl) are
• most important antigen Arenaviruses
a common source of these new genes and that the PREVENTION:
reassortment event leading to new human strains o NEURAMINIDASE
 The main mode of prevention
Bunyaviruses
occurs in pigs. • cleaves neuraminic acid (sialic acid) to release progeny virus from the Paramyxoviruses
infected cell is the vaccine, which contains
- Pigs may serve as the “mixing bowl” within which Orthomyxoviruses
• degrades the protective layer of mucus in the respiratory tract → both influenza A and B viruses
the human, avian, and swine viruses reassort.
enhances the ability of the virus to gain access to the respiratory (annual vaccination) Filoviruses
▪ Waterfowl: H1 to H16, N1 to N9
▪ Humans: H1 to H3, N1 and N2 epithelial cells. Rhabdoviruses
ANTIGENIC SHIFT ANTIGENIC DRIFT
Influenza B virus (Pandemics) (Epidemics)
- is only a human virus
- Major changes based on the - Minor changes based on
▪ there is no animal source of new RNA segments
reassortment of segments of the mutations in the genome RNA
- does not undergo antigenic shifts
genome RNA
- undergo enough antigenic drift that the current
- Example: when human influenza
strain must be included in the new version of the
A virus recombines with swine
influenza vaccine produced each year
influenza A virus
- no antigens in common with influenza A virus
- Sudden change in the molecular - Slow and progressive change in
structure of a microorganism → the composition of
new strain → little or no microorganisms → altered
acquired immunity to these immunological responses and
NOVEL strains → new epidemics susceptibility
or pandemics

SPECTRUM OF DISEASE
 Incubation period: 24-48 hours
 Fever, myalgia, headache, sore throat, and cough
 Complications:
- Fatal bacterial superinfection
• S. aureus
• S. pneumoniae
• H. influenzae
- Reye’s syndrome

51
 VIRUS MORPHOLOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
PARAMYXOVIRIDAE
Measles Virus Enveloped, helical, non- Respiratory droplet Measles virus infects the cells lining the URT → enters the blood → infects HP: Multinucleated  Vitamin A supplementation:
segmented ss-negative reticuloendothelial cells → spreads via the blood to the skin → cytotoxic T-cells attack the can reduce morbidity and
RNA
giant cells (Warthin-
measles virus-infected vascular endothelial cells in the skin → rash → virus can no longer be mortality from measles,
recovered → patient can no longer spread virus to other Finkelday bodies), particularly in malnourished
which form as a result of children
Can transiently depress cell-mediated immunity
the fusion protein in the
Infection confers lifelong immunity spikes, are characteristic PREVENTION Warthin-Finkelday bodies
of the lesions. Measles Vaccine
SPECTRUM OF DISEASE
- live attenuated vaccine
 aka red measles, rubeola, “first disease” - Given subcutaneously Cardinal Manifestations
 Incubation Period: 10-14 days - Age: 9 months of Measles

C
 Period of communicability: 4 days before and 4 days after the onset of the rash - may be given as early as 6
 Pathognomonic enanthem: Koplik’s spots (bright red lesions with a white central dot on months of age in cases of ough
the buccal mucosa) outbreaks oryza
 Timing of appearance of rash: Height of the fever onjunctivitis
 Cephalocaudal appearance of maculopapular rash (face – trunk – extremities – MMR Vaccine oplik spots
palms/soles) - Given subcutaneously
ENVELOPE SPIKES OF PARAMYXOVIRUSES  Rash fades in the same sequence in which it appears → branny desquamation and - Given at 15 months
Virus Hemagglutinin Neuraminidase Fusion Protein disappears within 7-10 days - 2 doses recommended
Measles (+) (-) (+)  Complications: PaRaMyxoviruses
Mumps (+) (+) (+) o Otitis Media POSTEXPOSURE PROPHYLAXIS
o Giant cell Pneumonia, Secondary Bacterial Pneumonia
Parainfluenza virus
RSV (-) (-) (+)  Measles Ig for prevention &
Parainfluenza (+) (+) (+) o Higher rate of activation of PTB attenuation within 6 days of RSV
o Subacute Sclerosing Panencephalitis (SSPE) / Dawson disease
Hemagglutinin: binds sialic acid and promotes viral entry
- neurodegenerative disease caused by persistent infection of the brain by an altered
exposure Measles
Neuraminidase: promotes progeny virion release  Measles Active Vaccine can
form of the measles virus; manifests 5-7 years after initial infection be given to susceptible children Mumps
 Final common pathway to a fatal outcome is the development of bronchiolitis obliterans >1yo within 72 hours
Mumps virus Enveloped, helical, non- Respiratory droplet - The virus infects the URT → spreads through the blood → infects the: PREVENTION Three MCC of viral
segmented (-)ssRNA o parotid glands → Parotitis (increase in pain when drinking citrus juices) MMR Vaccine (aseptic) meningitis
o testes → Orchitis - live attenuated vaccine
- Given subcutaneously  Mumps virus
o ovaries
o meninges → aseptic Meningitis - Given at 15 months  Coxsackie virus
o pancreas → Pancreatitis - 2 doses recommended  Echovirus
- Infection confers lifelong immunity

Respiratory Enveloped, helical, non- Respiratory droplet - Surface spikes are fusion proteins, not hemagglutinins or neuraminidase Ribavirin
segmented (-)ssRNA - Fusion protein causes cells to fuse, forming multinucleated giant cells (syncytia)
Syncytial Virus
(RSV) VIRAL PNEUMONIA Palivizumab (monoclonal
Humans are the antibody against F protein)
 RSV is the most important cause of pneumonia and bronchiolitis in infants
natural hosts of prevents pneumonia caused by
 Severe disease in infants due to immunologic cross-reaction with maternal antibodies
RSV. RSV infection in premature
RSV is also an important cause of otitis media in children and of pneumonia in the elderly
infants.
and in patients with chronic cardiopulmonary diseases.

Parainfluenza Enveloped, helical, non- Respiratory droplet LARYNGOTRACHEOBRONCHITIS / CROUP Racemic epinephrine
segmented (-)ssRNA  results in a “seal-like” barking cough and inspiratory stridor
virus 1 and 2
 Narrowing of upper trachea and subglottis → steeple sign on x-ray
 Severe croup can result in pulsus paradoxus secondary to upper airway obstruction.

In addition to croup, these viruses cause a variety of respiratory diseases such as the
common cold, pharyngitis, laryngitis, otitis media, bronchitis, and pneumonia.

52
 VIRUS MORPHOLOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
RHABDOVIRIDAE
Rabies virus Bullet-shaped Animal Reservoirs: - When a human is bitten, the virus replicates locally at the wound site for a few days, then HP: Negri bodies Pre-exposure:
enveloped, helical, non- Dogs, cats, skunks, migrates (15-100 mm/day) up to nerve axons to the CNS (retrograde transport) (cytoplasmic, round to Vaccine
segmented, (-)ssRNA raccoons, and bats oval, eosinophilic inclusions (PVRV or PDEV or PCEV – D0, D7,
SPECTRUM OF DISEASE and D21/28)
that can be found in
Transmission by Incubation 2 weeks to 6 years (depending on the site of the bite)
pyramidal neurons of the
animal bite Period The only time when vaccination is effective Post-exposure:
hippocampus and Purkinje
Prodrome Nonspecific symptoms of fever, headache, sore throat, fatigue, nausea cells of the cerebellum, Vaccine +/- Immunoglobulin
1st rabies symptom: pain / itchiness / paresthesia
Negri bodies
sites usually devoid of WHO GUIDELINES FOR POST-EXPOSURE PROPHYLAXIS
Acute ENCEPHALITIC / FURIOUS RABIES inflammation
neurologic - Phobic spasms: hydrophobia, aerophobia Category I Touching or feeding animals, No Treatment
period - Fluctuating consciousness licks on intact skin
Immunofluorescent Category II Minor scratches or abrasions Vaccine
- Autonomic instability
antibody test without bleeding or licks on
PARALYTIC / DUMB RABIES (IFAT): gold standard in broken skin and nibbling of
- Percussion myoedema: mounding of the muscles at the percussion site the detection of rabies uncovered skin
which disappears after a few seconds specific antigen Category III Single or multiple transdermal Vaccine +
Coma Follows the acute neurologic period, regardless of the presentation bites or scratches; Immunoglobulin
Death occurs secondary to respiratory center dysfunction contamination of mucous
Rabies has the highest case fatality ratio of any infectious disease membranes with saliva from
licks; exposure to bat
bites/scratches
All Category II exposures on
head and neck areas
FILOVIRIDAE: longest viruses
Ebola virus Enveloped, helical, non- Natural Host: fruit - targets endothelial cells, phagocytes, hepatocytes ELISA Supportive care, no definitive Ebola virus is named for the
segmented, (-)ssRNA bats of the - Incubation period: 2- 21 days treatment. river in Zaire that was the site
Pteropodidae family - abrupt onset of flu-like symptoms, diarrhea/vomiting, high fever, myalgia Antigen tests of an outbreak of
thread-like viruses - can progress to DIC, diffuse hemorrhage, shock Strict isolation of infected hemorrhagic fever in 1976.
Transmission: - high mortality rate (100%) RT-PCR individuals and barrier practices
direct contact with for health care workers are key
bodily fluids, to preventing transmission
fomites (including
dead bodies),
infected bats or
primates (apes/
monkeys)

53
 VIRUS MORPHOLOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
ENVELOPED RNA VIRUSES (POSITIVE SENSE)
CORONAVIRIDAE
Coronavirus Enveloped, helical, non- Reservoir: SPECTRUM OF DISEASE
segmented, (+)ssRNA Horseshoe bat COMMON COLDS
with prominent club-  Second to rhinovirus as the most common cause of common colds
shaped spikes form a Immediate host: SEVERE ACUTE RESPIRATORY SYNDROME
“corona” (halo) Civet cat  Incubation Period: 2-10 days (mean, 5 days)
 Receptor for SARS-CoV on surface of cells is angiotensin-converting enzyme-2 (ACE-2)
Two serotypes: Transmission:
 Binding of the virus to ACE-2 on the surface of respiratory tract epithelium → dysregulation
229E and OC43 Respiratory Droplet
of fluid balance → alveolar edema
 Severe atypical pneumonia rapidly progressing to ARDS
 Leukopenia and thrombocytopenia are seen
 CXR: interstitial “ground-glass” infiltrates that do not cavitate
MIDDLE EAST RESPIRATORY SYNDROME
 MERS-CoV binds to CD-26 on the respiratory mucosa (not ACE-2)
 clinical findings of MERS are similar to those of SARS
FLAVIVIRIDAE
Dengue virus Enveloped, icosahedral, Bite of female DENGUE FEVER (BREAKBONE FEVER) • NS1 Antigen: to detectPREVENTION: Dengue is the most
non-segmented, Aedes aegypti  Influenza-like syndrome characterized by biphasic fever, myalgia, arthralgia, rash, gene product (NS1  Insecticides common insect-borne viral
(+)ssRNA mosquito, Aedes leukopenia and lymphadenopathy  Draining stagnant water
glycoprotein) from day 1 disease in the world.
albopictus until day 6 from the  Mosquito repellent
Four serotypes: DENGUE HEMORRHAGIC FEVER
onset of fever 
  Dengue Vaccine FLAVIVIRUSES
DEN-1, 2, 3, 4  severe, often fatal, febrile disease characterized by capillary permeability, abnormalities of
hemostasis and a protein-losing shock syndrome - Dengvaxia® (CYD-TDV)  West Nile virus
(Each serotype Aedes aegypti is • RT-PCR: to detect dengue - first licensed in Mexico in
provides specific lifetime recognized by white  Hemorrhagic shock syndrome is due to the production of large amounts of cross-reacting  Hepatitis C and G virus
viral genes (RNA) in December 2015 for use in
immunity, and short- markings on its legs antibody at the time of a second dengue infection (antibody-dependent enhancement) acute phase serum  Yellow fever virus
individuals 9-45 years of
term cross-immunity) and a marking in DENGUE WITHOUT DENGUE WITH samples which coincide age living in endemic areas  Japanese enceph virus
the form of a lyre SEVERE DENGUE with the
onset of  Dengue virus
WARNING SIGNS WARNING SIGNS - live recombinant
on the upper Probable dengue: Lives in or travels to dengue- Lives in or travels to a viremia tetravalent dengue vaccine  Zika virus
surface of its thorax Lives in or travels to dengue- endemic area, with fever dengue-endemic area - given as a 3-dose series on
endemic area, with fever, plus any lasting for 2-7 days, plus any of with fever of 2-7 days and • Dengue IgM: marker of a 0/6/12-month schedule
two of the following: the following: any of the above clinical recent infection RNA viruses with
• Headache • Abdominal pain or tenderness manifestations for dengue icosahedral symmetry
• Body malaise • Persistent vomiting with or without warning • Dengue IgG: marker of
• Myalgia • Clinical signs of fluid signs, plus any of ▪ Flaviviruses
past infection; a fourfold ▪ Caliciviruses
• Arthralgia accumulation the following:
increase confirms the
• Retro-orbital pain • Mucosal bleeding • Severe plasma leakage, ▪ Reoviruses
diagnosis
• Anorexia • Lethargy, restlessness leading to: ▪ Picornavirus
• Nausea • Liver enlargement - Shock ▪ Togaviruses
• Vomiting • Laboratory: increase in Hct - Fluid accumulation with • CBC-PC: Characteristic
• Diarrhea and/or decreasing platelet respiratory distress findings are ▪ Hepevirus
• Flushed skin count • Severe bleeding thrombocytopenia with
• Rash (petechial, Herman’s sign) • Severe organ leukopenia. A
AND Confirmed dengue: impairment hematocrit level
• Laboratory test, at least CBC • Viral culture isolation - Liver: AST or ALT >1000 increase >20% is a sign
(leucopenia with or without • PCR - CNS: e.g., seizures, of hemoconcentration
thrombocytopenia) and/or dengue impaired consciousness and precedes shock.
NS1 antigen test or dengue IgM - Heart: e.g., myocarditis
antibody test (optional) - Kidneys e.g., renal failure
Confirmed dengue:
• Viral culture isolation
• PCR

54
 VIRUS MORPHOLOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
FLAVIVIRIDAE (continued)
Hepatitis C virus Enveloped, icosahedral, Humans are the PATHOGENESIS: Anti-HCV antibodies: ACUTE HEPATITIS C: A chronic infection is
non-segmented, reservoir for HCV. - Replication of HCV in the liver is enhanced by a liver-specific micro-RNA called miR-122. screening Peginterferon alfa characterized by elevated
(+)ssRNA This micro-RNA acts by increasing the synthesis of HCV mRNA. - significantly decreases the transaminase levels, a
HCV is the most
- Death of the hepatocytes is probably caused by immune attack by cytotoxic T cells Recombinant immunoblot number of patients who positive RIBA, and
prevalent blood-
Has at least six - Alcoholism greatly enhances the rate of hepatocellular carcinoma in HCV-infected assay (RIBA): confirmatory become chronic carriers detectable viral RNA for at
borne pathogen in
genotypes and multiple individuals. test least 6 months
the United States. CHRONIC HEPATITIS C:
subgenotypes based on - Rate of chronic carriage of HCV is much higher than that of HBV
differences in the genes • PCR–based test that combination of
Major mode of  Peginterferon alfa-2a
that encode one of its SPECTRUM OF DISEASE: detects the presence of
transmission:
two envelope - Incubation period: 8 weeks HCV-RNA (viral load) in  Ribavirin
blood-borne
glycoproteins. - Acute infection: milder than infection with HBV the serum should be If genotype 1, add:
Setting: IV drug
This genetic variation
users - Hepatitis C resembles hepatitis B as far as the ensuing chronic liver disease, cirrhosis, and performed to determine  Protease inhibitor
results in a the predisposition to hepatocellular carcinoma are concerned whether active disease - Boceprevir, Simeprevir,
“hypervariable” region - HCV infection also leads to significant autoimmune reactions and extrahepatic exists. Telaprevir
Minor modes:
in the envelope manifestations, including:
Needle-stick
glycoprotein. o Thyroiditis o DM Cirrhosis resulting from chronic
injuries, during
birth, sexual o Autoimmune hemolytic anemia o leukocytoclastic vasculitis HCV infection is the most
Genotype 1: most
common in US o ITP o  risk of B-cell NHL common indication for liver
o MPGN o lichen planus transplantation
o porphyria cutanea tarda
- HCV is the main cause of essential mixed cryoglobulinemia
Zika virus Enveloped, icosahedral, Aedes mosquito - Causes conjunctivitis, low-grade pyrexia, muscle and joint pain, malaise, headache, and Supportive care, no definitive Zika virus was first identified
non-segmented, bites itchy rash in 20% cases treatment. in Uganda in 1947.
(+)ssRNA - These symptoms are usually mild and last for 2-7 days.
Sexual and vertical
transmission Complications:
possible  Microcephaly
 Guillain-Barre Syndrome

Yellow Fever virus Enveloped, icosahedral, Reservoir: - characterized by jaundice and fever May see Councilman PREVENTION: Arbovirus is an acronym for
non-segmented, monkey or human - severe, life-threatening disease that begins with the sudden onset of fever, headache, bodies (eosinophilic  mosquito control arthropod-borne virus and
(+)ssRNA myalgias, and photophobia apoptotic globules) on liver  vaccine containing live, highlights the fact that these
- After this prodrome, the symptoms progress to involve the liver, kidneys, and heart biopsy attenuated yellow fever virus viruses are transmitted by
- Prostration and shock occur, accompanied by upper gastrointestinal tract hemorrhage arthropods, primarily
with hematemesis (“black vomit”) mosquitoes and ticks. Most
arboviruses are classified in
West Nile virus Enveloped, icosahedral, Bite of Culex - bird-mosquito-man cycle three families, namely,
non-segmented, mosquito - Virus transmitted via blood from bite site to brain.
togaviruses, flaviviruses,
(+)ssRNA Reservoir: Wild - Initial self-limited febrile illness with progression to neuroinvasive disease
and bunyaviruses
birds - The most important clinical picture is encephalitis with or without signs of
Humans are meningitis, typically in a person over 60 years of age.
dead-end hosts - Asymptomatic in 80%; fever and headache in 20%; encephalitis in 1%
Japanese B Enveloped, icosahedral, Bite of Culex - most common cause of epidemic encephalitis PREVENTION:
Encephalitis virus non-segmented, mosquitoes - most prevalent in Southeast Asia JE vaccine
(+)ssRNA - Thalamic infarcts on CT scan - live attenuated recombinant
Principal vector: monovalent viral vaccine
Culex - given 0.5ml subcutaneous for
tritaeniorhynchus children 12 months and above
summarosus - primary series: single dose
- booster dose: 12-24 months
after the 1st dose

55
 VIRUS MORPHOLOGY TRANSMISSION PATHOGENESIS / SPECTRUM OF DISEASE DIAGNOSIS TREATMENT / PREVENTION NOTES
TOGAVIRIDAE
Rubella virus Enveloped, icosahedral, Respiratory RUBELLA / GERMAN MEASLES / 3-DAY MEASLES PREVENTION: 5Bs of Congenital Rubella
non-segmented, droplets  Incubation period: 14-21 days MMR Vaccine Syndrome
(+)ssRNA  Period of communicability: 1 week before up to 1 week after the appearance of rash - live attenuated vaccine Bulag (cataracts)
Transplacentally  Prodrome: malaise, fever and anorexia for several days; may be accompanied by mild - Given subcutaneously
Only one known coryza and conjunctivitis (children may not have a prodrome) - Given at 15 months
Bingi (SN deafness)
serotype  Cephalocaudal appearance of maculopapular rash - 2 doses recommended Bobo (mental retardation)
 Postauricular lymphadenopathy: most characteristic clinical feature - should not be given to Butas puso (PDA)
 Enanthem: Forchheimer’s spots (petechiae on soft palate; not pathognomonic) immunocompromised patients Blueberry muffin rash
 polyarthritis caused by immune complexes (especially in adult women) or to pregnant women
 Natural infection leads to lifelong immunity.

CONGENITAL RUBELLA SYNDROME

 Risk is greatest early in fetal development when cell differentiation is at a peak (first
trimester)
 Rubivirus infected human embryo cells demonstrate chromosomal breakage and inhibition
of mitosis.
 Body areas affected in congenital rubella include:
o Heart: patent ductus, interventricular septal defects, pulmonary artery stenosis, etc.
o Eye: cataracts, chorioretinitis, etc.
o CNS: mental retardation, sensorineural deafness, microcephaly
 “blueberry muffin” appearance due to dermal extramedullary hematopoiesis

56
 RETROVIRIDAE p24
 Distinguished from all other RNA viruses by the presence of an  Group-specific antigen
unusual enzyme, reverse transcriptase → which converts a  Located in the core
single stranded RNA viral genome into a double-stranded viral  Not known to vary
DNA (ssRNA → dsDNA)  Antibodies against p24 do not neutralize HIV infectivity but
serve as important serologic markers of infection
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
gp120
CHARACTERISTICS:  Interacts with the CD4 receptor
 Enveloped virus with two copies (diploid) of a single-stranded  Gene mutates rapidly → many antigenic variants
positive polarity RNA genome  V3 loop: most immunologic region of gp120
 Most complex of the known retroviruses  Antibody neutralized HIV infectivity, but the rapid appearance
 Many serotypes of variants → difficult to prepare vaccine
 High mutation rate may be due to lack of an editing function in
STRUCTURE: the reverse transcriptase

gp41
 Mediates the fusion of the viral envelope with the cell
membrane at the time of infection

GENOME:
Gene Proteins Function
Structural genes found in all retroviruses
p24, p7 Nucleocapsid
gag
p17 Matrix
Reverse Transcribes RNA genome into DNA
transcriptase
pol Protease Cleaves precursor polypeptide
IntegraseIntegrates viral DNA into host cell DNA
Attachment to CD4 protein
gp120
env Antigenicity changes rapidly
gp41 Fusion with host cell → Inhibited by INFUVIRTIDE
 Transmembrane protein, TM (fusion protein, also called gp41), Regulatory genes found in HIV that are required for replication
which is linked to a surface protein, and SU (attachment Activation of transcription of viral genes
tat Tat
protein, gp120)
Transport of late mRNAs from nucleus to
 Cone-shaped, icosahedral core containing the major capsid rev Rev
cytoplasm
protein (CA also called p24)
Regulatory genes found in HIV that are not required for replication
 MA (outer matrix protein, p17) – directs entry of the double-
Decreases CD4 proteins and class I MHC
stranded DNA provirus into the nucleus, and is later essential
for the process of virus assembly. There are two identical
nef Nef proteins on surface of infected cells; induces
death of uninfected cytotoxic T cells
copies of the positive sense, single-stranded RNA genome in
Enhances infectivity by inhibiting the action
the capsid (that is, unlike other viruses, retroviruses are diploid)
 The RNA is tightly complexed with a basic protein, NC vif Vif of APOBEC3G (an enzyme that causes
hypermutation in retroviral DNA)
(nucleoprotein, p7), in a nucleocapsid structure that differs in
morphology among the different retrovirus genera. Transports viral core from cytoplasm into
vpr Vpr
nucleus in non-dividing cells
vpu Vpu Enhances virion release from cells

HIV Proviral Genome

Transmission: Pathogenesis:
 Original source: chimpanzees  Virus binds CD4 as well as a coreceptor, either CCR5 on
 Transfer of body fluids macrophages (early infection) or CXCR4 on T cells (late infection)
 Transplacental o The drug MARAVIROC is a CCR5 receptor antagonist.
 Perinatal  Preferentially infects and kills helper (CD4+) T lymphocytes
 Needlestick o Loss of cell-mediated immunity
o High probability of opportunistic infections
 also targets a subset of CD4+ cells called Th17 cells, which are
important mediator of mucosal immunity
o Th17 cells produce IL-17, which attracts neutrophils to the site
of bacterial infection.
oloss of Th17 cells → bloodstream infections by bacteria in the
normal flora of the colon (eg., E.coli)
 Main immune response consists of cytotoxic (CD8+) lymphocytes

57
STAGES OF INFECTION

Phase 0 Infection HIV acquired through sexual intercourse, DIAGNOSIS

blood, or perinatally  Presumptive diagnosis: detection of antibodies in the
Phase 1 Window Rapid viral replication but HIV test is patient’s serum to the p24 protein of HIV using ELISA.
Period negative o There are some false-positive results with this test
 Definitive diagnosis: Western blot (aka Immunoblot) analysis
Phase 2 Seroconversion Peak of viral load o Viral proteins are displayed by acrylamide gel electrophoresis,
Positive HIV test transferred to nitrocellulose paper (the blot), and reacted with
Mild flu-like illness lasting 1-2 weeks the patient’s serum.
Phase 3 Latent Period Asymptomatic o If antibodies are present in the patient’s serum, they will bind to
the viral proteins (predominantly to the gp41 or p24 protein).
CD4 goes down
o Enzymatically labeled antibody to human IgG is then added.
Lasts 1-15 years o A color reaction reveals the presence of the HIV antibody in the
Phase 4 Early CD4 500 to 200 infected patient’s serum.
Symptomatic Lasts 5 years ELISA WESTERN BLOT
Mild mucocutaneous, dermatologic, and Presumptive diagnosis Definitive diagnosis
hematologic illnesses sensitive specific
high false positive rate low false positive rate
Phase 5 AIDS CD4 <200 low threshold high threshold
Lasts 2 years rule out test rule in test
AIDS-defining illnesses develop
 HIV can be grown in culture from clinical specimens, but this
AIDS-DEFINING ILLNESSES procedure is available only at a few medical centers.
CD4 ETIOLOGY CLINICAL SYNDROME
 The PCR is a very sensitive and specific technique
M. tuberculosis Disseminated tuberculosis o can be used to detect HIV DNA within infected cells
HSV HSV esophagitis o Some individuals who do not have detectable antibodies
<500
C. albicans Esophageal candidiasis have been shown by this test to be infected.
HHV-8 Kaposi sarcoma o The amount of viral RNA in the plasma (i.e., the viral
P. jiroveci PCP pneumonia load) can also be determined using PCR-based assays.
T. gondii Cerebral toxoplasmosis
<200 C. neoformans Meningoencephalitis TREATMENT
C. immitis Coccidioidomycosis  Highly active antiretroviral therapy
C. parvum Chronic diarrhea
M. avium Invasive pulmonary disease
<50 H. capsulatum Histoplasmosis
CMV CMV retinitis

AIDS-DEFINING ILLNESS: Prevalence

P. carinii pneumonia (PCP) 42.6%
Esophageal candidiasis 15.0%
Wasting 10.7%
Kaposi sarcoma 10.7%
Disseminated MAC 4.8%

COMMON OPPORTUNISTIC INFECTIONS

Site of Infection Disease or Symptom Causative Organism
Lung 1. Pneumonia Pneumocystis jiroveci, CMV
2. Tuberculosis Mycobacterium tuberculosis
Mouth 1. Thrush Candida albicans
2. Hairy leukoplakia Epstein-Barr virus
3. Ulcerations HSV-1, Histoplasma capsulatum
Esophagus 1. Thrush Candida albicans
2. Esophagitis CMV, HSV-1
 Immune reconstitution inflammatory syndrome (IRIS)
Intestinal tract Diarrhea Salmonella sp., Shigella sp,
CMV, Cryptosporidium parvum, describes a collection of inflammatory disorders associated
Giardia lamblia with paradoxical worsening of preexisting infectious processes
Central nervous 1. Meningitis Cryptococcus neoformans (HBV, HCV, MAC, MAI, etc) following the initiation HAART in
system 2. Brain abscess Toxoplasma gondii
HIV-infected individuals
3. Progressive multifocal JC virus
leukoencephalopathy
Eye Retinitis CMV PREVENTION
Skin 1. Kaposi's sarcoma HHV-8 General Prevention:
2. Zoster Varicella-zoster virus  Condoms, not sharing needles, proper blood disposal,
3. Subcutaneous nodules Cryptococcus neoformans
Reticulo- Lymphadenopathy or Mycobacterium avium complex,
postexposure prophylaxis
endothelial system splenomegaly Epstein-Barr virus
Perinatal Prevention:
The two most characteristic manifestations of AIDS are Pneumocystis  Perinatal Prophylaxis, cesarean delivery, breastfeeding
pneumonia and Kaposi’s sarcoma. cessation

58
HIGHLY ACTIVE ANTIRETROVIRAL THERAPY (HAART):
 Often initiated at the time of HIV diagnosis.
 Strongest indication for patients presenting with AIDS-defining illness, low CD4+ cell counts (< 500 cells/mm3), or high viral
load
 Regimen consists of 3 drugs to prevent resistance: 2 NRTIs (zidovudine and lamivudine) and protease inhibitor (indinavir)

59
HEPATITIS VIRUSES

• ALL HEPATITIS VIRUSES HAVE EPISODES OF FEVER, ELEVATED TRANSAMINASES (ALT AND AST) AND JAUNDICE
• HBV DNA POLYMERASE HAS DNA AND RNA-DEPENDENT ACTIVITIES
• THE DNA POLYMERASE THEN REVERSE TRANSCRIBES VIRAL RNA TO DNA, WHICH IS THE GENOME OF THE PROGENY VIRUS
• HCV LACKS EXONUCLEASE THUS NO PROOFREADING ACTIVITY

VIRUS HEPATITIS A HEPATITIS B HEPATITIS C HEPATITIS D HEPATITIS E

FAMILY RNA PICORNAVIRUS DNA HEPADNAVIRUS RNA FLAVIVIRUS RNA DELTAVIRUS RNA HEPEVIRUS
TRANSMISSION FECAL-ORAL PARENTERAL, PERINATAL PRIMARILY BLOOD (IV DRUG PARENTERAL, FECAL-RAL ROUTE ESPECIALLY
USER, POST TRANSFUSION) PERINATAL,SEXUAL WATER-BORNE
INCUBATION PERIOD SHORT (WEEKS) LONG (MONTHS) LONG SUPERINFECTION (HDV AFTER SHORT
HBV)
SHORT(CO-INFECTION HDV
AND HBV)
CLINICAL COURSE ASYMPTOMATIC (USUALLY INITIALLY LIKE SERUM SICKNESS MAY PROGRESS TO SIMILAR TO HBV FULMINANT HEPATITIS IN
ACUTE) FEVER, ARTHRALGIAS, RASH, CARCINOMA OR CIRRHOSIS EXPECTANT PREGNANT
MAY PROGRESS TO WOMEN
CARCINOMA
HEPATOCELLULAR CARCINOMA NO YES YES YES NO
RISK
LIVER BIOPSY HEPATOCYTE SWELLING, GRANULAR EOSINOPHILIC LYMPHOID AGGREGATES WITH GRANULAR EOSINOPHILIC PATCHY NECROSIS
MONOCYTE INFILTRATION, “GROUND GLASS” FOCAL AREAS OF “GROUND GLASS”
COUNCILMAN BODIES APPEARANCE, CYTOTOXIC T MACROVESICULAR STEATOSIS APPEARANCE, CYTOTOXIC T
CELL MEDIATED DAMAGE CELL MEDIATED DAMAGE
NOTES NO CARRIER STATE COMMON WITH CARRIER CARRIER STATE IS VERY DEFECTIVE VIRUS, DEPENDENT ENETERIC, EPIDEMIC (NO
STATE COMMON HBV HBSG COAT FOR ENTRY CARRIER STATE)
INTO HEPATOCYTES

60
 Number Other names for the disease Etiology(ies)
First disease Rubeola Measles virus
Measles
Hard measles
14-day measles
Morbiliform
Second disease Scarlet Fever Streptococcus pyogenes
Scarlatina
Third disease Rubella Rubella virus
German measles
3-day measles
Fourth disease Filatow-Dukes' Disease Some say the disease does not exist. Others believe it is due
Staphylococcal Scalded Skin Syndrome to Staphylococcus aureus strains that make epidermolytic (exfoliative)
Ritter's disease toxin
Fifth disease Erythema infectiosum Erythrovirus (Parvovirus) B19
Sixth disease Exanthem subitum Human Herpes Virus 6 or Human Herpes Virus 7
Roseola infantum
"Sudden Rash"
Rose rash of infants
3-day fever

61
MEDICAL PARASITOLOGY CALDERON, REÑA, MANN
PROTOZOA PARASITE BIOLOGY
INTESTINAL PROTOZOA
Entamoeba  Pseudopod-forming
histolytica nonflagellated protozoa
→ Brownian movement
 Most invasive parasite
among Entamoeba
 Eukaryotic organism that
lack membrane-bound
organelles
Giardia lamblia  Flagellate that lives in the
duodenum, jejunum, and
upper ileum
 Falling leaf motility
 Simple asexual life cycle
 Covered with variant
surface proteins
TRANSMISSION INFECTIVE STAGE DIAGNOSTIC STAGE
Fecal-oral Mature Cysts Trophozoite
- found in diarrheal stools
and within the intestinal
and extraintestinal lesions
- characteristically contain
ingested red blood cells
(erythrophagocytosis) →
hematophagous
- nucleus has a small central
nucleolus and fine
chromatin granules along
the border of the nuclear
membrane
Cyst
- predominates in non-
diarrheal stools
- smaller than E. coli
- has four nuclei (E. coli has 8)
Fecal-oral Cysts Trophozoite
- found only in diarrheal
stools
- pear-shaped with two
nuclei, four pairs of flagella, cytoskeleton
and a suction disk with
which it attaches to the
intestinal wall
Cyst
- found in diarrheal and
formed stools
PATHOGENESIS/VIRULENCE FACTORS SPECTRUM OF DISEASE TREATMENT NOTES
 Lectin: mediates adherence ASYMPTOMATIC CYST CARRIER STATE ASYMPTOMATIC CYST
 Amebapores: for penetration CARRIER STATE
AMEBIC COLITIS  Diloxanide furoate
 Cysteine proteases: for cytopathic
 Dysentery without fever (DOC)
effect
 Flask-shaped colon ulcer  Iodoquinol
 Paromomycin
Ingestion of cysts AMEBOMA
 granulomatous lesion that may form in AMEBIC COLITIS Trophozoites (with
cyst produces trophozoites in the the cecal or rectosigmoid areas  Metronidazole engulfed RBCs in the
intestine  associated with dystentery  Tinidazole cytoplasm)
amebic dystentery in the colon AMEBIC LIVER ABSCESS  Diloxanide furoate
 Paromomycin
 Most common extraintestinal form
spread to the liver (MC), lung, brain  Usually in the posterosuperior aspect
AMEBIC LIVER ABSCESS
of the right lobe
- This is according to majority of  Metronidazole
references. But according to Schwartz,  Tinidazole
it is the superior-anterior aspect.  Percutaneous drainage
 Anchovy paste-like aspirate (thick for nonresponders
chocolate brown in color)
 Adhesive disc and lectin facilitate ACUTE INFECTION  Metronidazole
attachment to avoid peristalsis  abdominal pain
 Villous flattening, crypt  watery, foul-smelling diarrhea
hypertrophy and disruption of  excessive flatus, smelling like rotten
eggs
 Ultimately leads to enterocyte  No fever and non-bloody (does not
apoptosis invade the mucosa and does not enter the
 trophozoite causes inflammation of
bloodstream)
Multinucleated
the duodenal mucosa → trophozoites
CHRONIC INFECTION
malabsorption of protein and fat.  constipation, weight loss, and STRING TEST: swallowing
a weighted piece of string
steatorrhea
→ trophozoites adhere to
the string and can be
visualized after
withdrawal
62
 PROTOZOA PARASITE BIOLOGY TRANSMISSION INFECTIVE STAGE DIAGNOSTIC STAGE PATHOGENESIS/VIRULENCE FACTORS SPECTRUM OF DISEASE TREATMENT NOTES
Cryptosporidium  Opportunistic infection Fecal-oral Thick-walled - Thick-walled oocysts  The oocysts excyst in the small  Self-limited nonbloody diarrhea in  Nitazoxanide:
oocysts using a modified Kinyoun intestine, where the trophozoites immunocompetent patients DOC for immuno-
hominis / parvum  Undergoes schizogony and
acid-fast stain (and other forms) attach to the gut  Severely debilitating prolonged diarrhea if competent patients
gametogony wall. CD4 <200 (due to autoinfection)
 Invasion does not occur.  NO effective drug
 Autoinfection in
 The jejunum is the site most heavily therapy for severely
immunocompromised
infested. immunocompromised
patients
patients, but Oocysts on acid-fast
 Acid-fast organism paromomycin may be stain
useful in reducing
diarrhea.

 HAART for HIV patients

63
 PROTOZOA PARASITE BIOLOGY
INTESTINAL PROTOZOA (continued)
Balantidium coli  only ciliated protozoan
that causes human
disease (i.e., diarrhea)
 Largest protozoan
parasite of humans
 Pigs are the main reservoir
→ diarrhea among
slaughter house workers
UROGENITAL PROTOZOA
Trichomonas  Exists only as
vaginalis trophozoite
 Pear-shaped flagellated
trophozoite with jerky
motion
 cannot exist outside human
because it cannot form cysts
Life cycle of Entamoeba histolytica, showing the sites of action of amebicidal drugs
TRANSMISSION INFECTIVE STAGE DIAGNOSTIC STAGE PATHOGENESIS/VIRULENCE FACTORS SPECTRUM OF DISEASE TREATMENT NOTES
Fecal-oral Cysts Diagnosis is made by finding BALANTIDIASIS /  Tetracycline:
large ciliated trophozoites or BALANTIDIAL DYSENTERY treatment of choice
large cyst with a  B. coli is locally invasive, causing
characteristic V-shaped colonic ulcers (round-based, wide-  Metronidazole
nucleus in the stool necked intestinal ulcers)
 extraintestinal lesions do not occur
(unlike the case with E. histolytica)
Sexual intercourse Trophozoites Trophozoites TRICHOMONIASIS  Metronidazole 2g
(“ping-pong” (seen in wet mount of  Watery, foul-smelling, greenish single dose
transmission) vaginal fluid) discharge accompanied by itching and - Treat both the
burning patient and the
 Strawberry cervix partner
Motile Trophozoites
THE COMMENSAL AMOEBA
- non-invasive and do not cause disease
- reproduce by binary fission
- cysts pass through the acidic stomach unscathed, protected by their cyst wall
- excystation occur in the small intestine
Entamoeba dispar morphologically similar to E. histolytica but their DNA and ribosomal RNA are
different
Entamoeba hartmanni similar to E. histolytica but is much smaller and does not ingest RBC, sluggish
Entamoeba coli cosmopolitan in distribution, harmless inhabitant of colon, has a larger cyst and
greater number of nuclei than E. histolytica
Entamoeba polecki parasite of pigs and monkey, cyst is uninucleated
Entamoeba gingivalis has no cyst stage and does not inhabit the intestines, found in the mouth,
moves quickly and has numerous blunt pseudopodia, transmission is via kissing
or droplet spray
Endolimax nana small size, sluggish movement
Iodamoeba butschlii no peripheral chromatin granules on the nuclear membrane
64
 PROTOZOA PARASITE BIOLOGY TRANSMISSION INFECTIVE STAGE DIAGNOSTIC STAGE PATHOGENESIS/VIRULENCE FACTORS SPECTRUM OF DISEASE TREATMENT NOTES
BLOOD AND TISSUE PROTOZOA
Plasmodium  Most important parasitic Bite of infected Sporozoites Trophozoites (ring forms)  Most of the pathologic findings of  Paroxysmal fever with malaise and bone PREVENTION BUZZ WORDS
species disease in man female mosquito malaria result from the destruction pains  Chemoprophylaxis
(Anopheles  Hemolytic anemia, jaundice,  Insecticide-treated nets Infected RBC with 1-2
of RBCs.
splenomegaly  Insect repellants with small chromatin dots
 ASEXUAL life cycle consists minimus DIAGNOSTIC TESTS FOR MALARIA - enlarged spleen characteristic
 Parasitic pneumonitis DEET → P. falciparum
of schizogony and flavirostris)  Thick and thin smears with Giemsa stain of malaria is due to congestion of
gametogony sinusoids with erythrocytes,  Cerebral malaria  Biological modification
- Thick smear: to screen for the presence of
coupled with hyperplasia of - Malarial or Durck granulomas → cultivation of snails infected RBC
transmission organism
lymphocytes and macrophages  Acute Renal Failure (Blackwater fever) that eat up mosquito with presence of ring
 SEXUAL life cycle involves across the - Thin smear: for species identification
placenta, in blood  Septic shock (algid malaria) larvae form stage only → P.
sporogony - HIGHEST YIELD WHEN BLOOD SAMPLES
transfusions, and  People with RBC defects (G6PD falciparum
TAKEN DURING FEVER OR 2-3 HOURS AFTER
by intravenous PEAK deficiency, sickle cell) are SPECIAL CLINCAL OUTCOMES
Areas of High Areas of Chloroquine  RECRUDESCENCE infected RBC
drug use also protected against the severe effects
Endemicity Resistance occurs - Recurrence of symptoms after a with presence of
of falciparum malaria
 Palawan  Palawan temporary abatement (2-4 weeks) band form stages →
 Kalinga- Apayao  Davao del Norte - Seen in P. falciparum and P. P. malariae
 Partial immunity based on humoral
 Ifugao  Campostela Valley malariae
antibodies that block merozoites
 Agusan del Sur from invading the red cells occurs in
infected individuals (premunition)  RELAPSE
- Results to low level of - Return of disease after its apparent
COMPARISON OF SPECIES
parasitemia and low-grade cessation (1-6 months) due to
P. falciparum P. malariae P. vivax P. ovale
symptoms reactivation of hypnozoites
Asexual cycle 48 hours 72 hours 48 hours 48 hours
- Seen in P. ovale and P. vivax
Periodicity Malignant Benign Benign Benign
tertian quartan tertian tertian
RBC preference All ages Old RBC Young RBC Young RBC
Parasitemia Highest Lowest Low Low Clinical Setting Drug Therapy Alternative Drug
Merozoites 0 6-12 12-24 8 Chloroquine-sensitive P.
Gametocytes Banana- Large Small falciparum and P. Chloroquine
Compact malariae infections PROPHYLAXIS
shaped round round Drug Prophylactic Use
P. vivax and P. ovale
Cerebral Chloroquine + Primaquine
Yes No No No infections Chloroquine Areas WITHOUT resistant P. falciparum
Malaria
Recrudescence Yes Yes No No Malarone (Atovaquone- Malarone
Uncomplicated Areas WITH chloroquine-resistant P. falciparum
Relapse No No Yes Yes Proguanil)
Infections with Quinine + Doxycycline/ Mefloquine
Drug Resistance Many Few Few Few OR Mefloquine
chloroquine-resistant P. Clindamycin
Malarial Dots Maurer Ziemann Schuffner Schuffner OR Co-Artemether + Doxycycline Areas with MULTIDRUG-resistant P. falciparum
falciparum
Lumefrantine
Terminal prophylaxis of P. vivax and P. ovale
MALARIAL DOTS PRESENT IN INFECTED RBCs: Primaquine infection; alternative for primary prevention
Artesunate + Doxycycline/
SCHUFFNER MAURER ZIEMANN Severe or complicated Clindamycin Artemether +
Punctate Coarse
infections with P. OR Mefloquine/Malarone Doxycycline/Clindamycin
Fine dots falciparum OR Mefloquine/Malarone
granulations granulations OR Quinidine gluconate
P. vivax SPECIAL SITUATIONS
P. falciparum P. malariae
P. ovale Chloroquine-resistance Mefloquine + Doxycycline
Eradication of hypnozoites Primaquine
Severe cases or pregnant Quinidine or Quinine

65
Action of chloroquine on the formation of hemozoin by Plasmodium species.

66
 PROTOZOA PARASITE BIOLOGY TRANSMISSION INFECTIVE STAGE DIAGNOSTIC STAGE PATHOGENESIS/VIRULENCE FACTORS SPECTRUM OF DISEASE TREATMENT NOTES
BLOOD AND TISSUE PROTOZOA (continued)
Toxoplasma  Tissue protozoan
gondii
Ingestion of cysts Fecal oocysts Trophozoites (Bradyzoites) Two Types of Trophozoites:  IMMUNOCOMPETENT: Treatment of Choice:
in raw meat, TACHYZOITES - Usually asymptomatic Sulfadiazine + Heterophil-Positive:
 Domestic cat is the contaminated  For the diagnosis of acute - rapidly multiplying - some resemble infectious Pyrimethamine  Epstein-Barr Virus
definitive host food and congenital infections, - cell-mediated immunity usually mononucleosis, except that the
an immunofluorescence limits the spread of tachyzoites heterophil antibody test is negative For patients who cannot Heterophil-Negative:
 Humans and other Transplacentally assay for IgM antibody is - seen in body fluids in early,  Cytomegalovirus
receive sulfa drugs,
mammals are used. acute infections  IMMUNOCOMPROMISED:  Toxopasma
clindamycin can be
intermediate hosts  Microscopic examination of - encephalitis
added to
Giemsa-stained BRADYZOITES - brain abscesses usually seen as
pyrimethamine.
preparations shows - slowly multiplying multiple ring-enhancing lesions on Intracranial:
- contained in cysts in muscle and MRI  Toxoplasmosis
crescent-shaped
trophozoites during acute brain tissue and in the eye
Periventricular:
infections.  CONGENITAL TOXOPLASMOSIS
- Can result in abortion, stillbirth or  Cytomegalovirus
 Cysts may be seen in the
tissue. neonatal disease with
hydrocephalus, encephalitis,
chorioretinitis, and
hepatosplenomegaly
- Fever, jaundice, and intracranial
calcifications are also seen

Leishmania  Flagellate protozoa Bite of the female Promastigotes Amastigote LEISHMANIASIS Conventional Therapy:
species sandfly of the CUTANEOUS MUCOCUTANEOUS VISCERAL Sodium
genus Causative L. tropica stibogluconate
Phlebotomus or Examination of Giemsa- Agent L. braziliensis L. donovani (Pentavalent antimonial)
L. mexicana
Lutzomyia stained tissue and fluid Local Name Oriental Sore Espundia Kala-azar
samples for the Second-line agents:
Presentation ulcerating single or parasite attacks infects macrophages
nonflagellated form multiple skin sores tissue at the → migrate to the Amphotericin B
(amastigote), which is the mucosal-dermal spleen, liver, and Pentamidine
only form that occurs in junctions of the bone marrow →
humans and other mammals. nose and mouth → parasite rapidly
Macrophages containing multiple lesions multiplies →
L. donovani amastigotes hepatosplenomegaly

Babesia microti  Sporozoan Bite Ixodes tick Giemsa-stained blood smears  Babesia infects RBCs, causing them BABESIOSIS Mild to moderate
(same as Borrelia reveal intraerythocytic cytic to lyse, but unlike plasmodia, it has  Influenza-like symptoms begin gradually disease:
burgdorferi of ring shaped trophozoites are no exoerythrocytic phase. and may last for several weeks Atovaquone +
Lyme disease) often in tetrads in the form  Hepatosplenomegaly and anemia occur Azithromycin
of a Maltese cross  Asplenic patients are affected
more severely. Severe disease:
Quinidine +
Clindamycin “Maltese cross”
Cyclospora  Coccidial sporozoa Fecal–oral Spherical oocyst in a causes watery diarrhea in both Trimethoprim-
(contaminated modified acid-fast stain of a immunocompetent and Sulfamethoxazole
cayetanensis
water supplies) stool sample immunocompromised individuals

Isospora belli  Coccidial sporozoa Fecal–oral Oocyst typical oocyst in fecal The oocysts excyst in the upper small The disease in immunocompromised Trimethoprim-
transmission of specimens intestine and invade the mucosa, patients presents as a chronic, profuse, Sulfamethoxazole
oocysts causing destruction of the brush watery diarrhea
border

67
 PROTOZOA PARASITE BIOLOGY TRANSMISSION INFECTIVE STAGE DIAGNOSTIC STAGE PATHOGENESIS/VIRULENCE FACTORS SPECTRUM OF DISEASE TREATMENT NOTES
BLOOD AND TISSUE PROTOZOA (continued)
Trypanosoma  Blood and tissue protozoan Feces of Reduviid Metacyclic Trypomastigote in blood  Many cells can be affected, but CHAGAS’ DISEASE / AMERICAN Drug of choice for the
 All four forms: bug (“kissing trypomastigote smear myocardial, glial, and TRYPANOSOMIASIS acute phase:
cruzii
- Amastigote bug,” triatoma, reticuloendothelial cells are the  ACUTE PHASE: Nifurtimox
- Promastigote most frequent sites. - facial edema
or cone-nose)
- Epimastigote deposited in a - nodule (chagoma) near the bite Alternative Drug:
 a stained preparation of a  Cardiac muscle is the most - fever, lymphadenopathy,
- Trypomastigote painless bite Benznidazole
bone marrow aspirate frequently and severely affected hepatosplenomegaly
(Kiss is supposedly
or muscle biopsy tissue - unilateral palpebral swelling
painless)
specimen (which may  neuronal damage leads to cardiac (Romaña’s sign) There is no effective
reveal amastigotes) arrhythmias and loss of tone in the - resolves in about 2 months drug against the
 culture of the organism on colon (megacolon) and esophagus chronic form.
(megaesophagus)  CHRONIC FORM:
special medium
- myocarditis, dilated cardiomyopathy
Trypomastigote in  Xenodiagnosis: allowing with apical atrophy
blood smear an uninfected, laboratory- - megacolon, megaesophagus
raised reduviid bug to feed (secondary achalasia)
on the patient and, after - Death is usually due to cardiac
several weeks, examining arrhythmias or congestive heart
the intestinal contents of failure
the bug for the organism
- leading cause of CHF in Latin
America
Trypanosoma  Blood and tissue protozoan Tsetse fly Metacyclic Trypomastigote in blood  Trypomastigotes spread from the skin → blood → lymph nodes → brain Suramin for
 Only two forms: (Glossina), a trypomastigote  The typical somnolence (sleeping sickness) progresses to coma as a result of a bloodborne disease
brucei
- Epimastigote painful bite demyelinating encephalitis (ARAS, brainstem)
- Trypomastigote  In the acute form, a cyclical fever spike (approx. every 2 weeks) occurs that is Melarsoprol for
 exhibit remarkable related to antigenic variation. CNS penetration
antigenic variation of
their surface glycoproteins AFRICAN TRYPANOSOMIASIS / AFRICAN SLEEPING SICKNESS Morula cells of Mott
 initial lesion: indurated skin ulcer (“trypanosomal chancre”) at the site of the
Trypanosoma brucei gambiense Trypanosoma brucei rhodesiense fly bite
 causes the disease along water courses  found in the arid regions of east Africa  intermittent weekly fever and lymphadenopathy
in west Africa  enlargement of the posterior cervical lymph nodes (Winterbottom’s sign) MELlow music will
Trypomastigote in  deep hyperaesthesia (Kerandel's sign) SURely put you to
 runs a low-grade chronic course  causes a more acute, rapidly
blood smear  Encephalitis → excessive somnolence SLEEP.
over a few years progressive disease that, if untreated, is
• Morula cells of Mott: plasma cells with cytoplasmic immunoglobulin
usually fatal within several months MELarsoprol and
 Transmitted by Glossina  Transmitted by Glossina
globules
SURamin for African
 Untreated disease is usually fatal as a result of pneumonia.
palpalis (or riverine tsetse) morsitans (or savannah tsetse) SLEEPing sickness
 Treatment:  Treatment:
Stage 1 Stage 2 • Suramin (to clear parasitemia)
Pentamidine Eflornithine followed by Melarsoprol
Suramin Melarsoprol

Acanthamoeba  free-living amebas carried into the Trophozoites Occur primarily in  KERATITIS: most common disease Pentamidine,  MC parasite that
 Most common protist in soil skin or eyes immunocompromised individuals associated with Acanthamoeba infection ketoconazole, or contaminates
castellani
during trauma  GRANULOMATOUS AMEBIC flucytosine contact lenses
ENCEPHALITIS
Naegleria fowleri  free-living amebas Swimming in Trophozoites occur in otherwise healthy persons  PRIMARY AMEBIC Amphotericin-B
freshwater Trophozoites can penetrate the nasal MENINGOENCEPHALITIS
lakes mucosa and cribriform plate

68
 PROTOZOA PARASITE BIOLOGY TRANSMISSION INFECTIVE STAGE DIAGNOSTIC STAGE PATHOGENESIS/VIRULENCE FACTORS SPECTRUM OF DISEASE TREATMENT NOTES
DINOFLAGELLATES
Dinoflagellates  Flagellated marine protists Eating bivalve  Filter feeders accumulate toxins produced by dinoflagellates  Gastric lavage with
 Algal blooms cause red mollusks SHELLFISH POISONING SYNDROMES
activated charcoal
tide (mussels, clams,  Supportive fluid
Syndrome Toxin Incubation Clinical presentation
 Most common in the oysters, and resuscitation
Philippines is Pyrodinium scallops) and fish Facial paresthesia, total
Paralytic Saxitoxin
paralysis, respiratory failure
bahamense var. obtained from red 15 mins  Endotracheal
compressum tide Facial paresthesia, slurred intubation for
Neurotoxic Brevetoxin
speech, ataxia, diarrhea respiratory failure
Diarrhea, nausea and vomiting,
Diarrhetic Okadaic acid  Neostigmine and
abdominal pain
30 mins edrophonium to
Diarrhea, short-term memory improve muscle
Amnesic Domoic acid
loss, seizures weakness

PLATYHELMINTHES
Species Transmission Intermediate Host Site Affected Treatment
CESTODES / TAPEWORMS
Eggs/larvae in undercooked
Taenia solium Pigs Intestine Praziquantel
pork
Taenia saginata larvae in undercooked beef Cattle Intestine Praziquantel
Diphyllobothrium latum larvae in undercooked fish Fish Intestine Praziquantel
Eggs in food contaminated
Echinococcus granulosus Swine Liver Albendazole
with dog feces
TREMATODES / FLUKES
Schistosoma japonicum Penetrate skin Snail Blood Praziquantel
Pargonimus westermani Ingested with raw crab Snail and crab Lung Praziquantel
Clonorchis sinensis Ingested with raw fish Snail and fish Liver Praziquantel

ASCHELMINTHES / NEMATODES
Location Species Disease Transmission Treatment
Ascaris lumbricoides Ascariasis Ingestion of eggs Albendazole
Ancylostoma duodenale
Hookworm Larval penetration of skin Albendazole
Necator americanus
Intestines Trichuris trichiura Whipworm Ingestion of eggs Mebendazole
Enterobius vermicularis Pinworm Ingestion of eggs Pyrantel pamoate
Strongyloides stercoralis Strongyloidiasis Larval penetration of skin Ivermectin
Capillaria phiippinensis Capillariasis Eggs in undercooked fish Albendazole
Wuchereria bancrofti Diethylcarbamazine
Filariasis Mosquito bite
Tissue Brugia malayi (DEC)
Trichinella spiralis Trichinosis Eggs in undercooked meat Thiabendazole

69
CESTODES / FLATWORMS Taenia solium Taenia saginata Diphyllobothrium latum Echinococcus granulosus
Parasite Biology / Scolex: has four suckers and circle of hooks arranged around a rostellum Scolex: has four suckers but, longest of the tapeworms composed of a scolex and only three
Characteristics Gravid proglottids: have 5 -10 primary uterine branches no hooklets (no rostellum) Scolex: has two elongated sucking proglottids → one of the smallest
Gravid proglottids: have 15-25 grooves for attachment; no hooks tapeworms
T. solium T. saginata
Suckers 4 4 primary uterine branches Proglottids: wider than they are long; Scolex: circle of hooks and four
Rostellum (+) (-) gravid uterus is in the form of a rosette suckers (similar to T. solium)
Uterine Branches 5-10 15-25 Have oval and operculated eggs
Intermediate Host Pigs Cattle Copepods (first IH) and fish (second IH) Sheep / Humans (accidental IH)
Infective stage Larvae (cysticerci) Eggs Larvae (cysticerci) Plerocercoid / sparganum larvae Eggs
Mode of Transmission Ingestion of larvae (cysticerci) in Ingest eggs in food or water Ingestion of larvae (cysticerci) in Ingestion of plerocercoid larvae in Ingestion eggs in food contaminated with
undercooked pork contaminated with human feces undercooked beef undercooked fish dog feces (Dog is the definitive host)
Stage in Humans Adult tapeworm in intestine, Cysticercus, especially in brain; Adult tapeworm in intestine, Adult tapeworm in intestine can cause Larva causes unilocular hydatid cyst
Associated with Disease causing taeniasis causing cysticercosis causing taeniasis diphyllobothriasis disease, especially in liver and lung
Sites Affected Intestine Brain and eyes Intestine Intestine Liver, lungs, and brain (hydatid cysts)
Signs and symptoms Mild intestinal symptoms Brain (neurocysticercosis): Abdominal pain Abdominal pain Liver cysts → hepatic dysfunction
headache, vomiting, seizure Weight loss Diarrhea Pulmonary cysts → erode into a bronchus
Pruritus ani Vitamin B12 deficiency caused by → bloody sputum
Eyes: uveitis or retinitis, larvae in Intestinal obstruction preferential uptake of the vitamin by Cerebral cysts → headache and focal
viterous the worm → megaloblastic anemia neurologic signs.
Rupture of cyst → anaphylactic shock
Diagnosis/Diagnostic Stage Gravid Proglottids in stool Biopsy, CT scan Gravid Proglottids in stool Unembryonated operculated eggs in Biopsy, CT Scan, serology
stool
Treatment Praziquantel Praziquantel, Albendazole, or Praziquantel Praziquantel Albendazole, or surgical removal of cyst
surgical removal of cysticerci PAIR procedure: Puncture, Aspiration,
Injection, Reaspiration
Pathogenesis Ingested larvae (cysticerci) in small Ingestion of eggs in food or water Taeniasis similar with T. solium See diagram on the next page Worms in the dog’s intestine liberate
(see diagrams on the intestine attach to gut wall contaminated with human feces thousands of eggs
  
next page) eggs hatch in the small intestine T. saginata does NOT cause Eggs ingested by sheep (or humans)
Grow into adult worms → taeniasis
  cysticercosis in humans. 

Gravid proglottid containing eggs detach oncospheres burrow through the wall into Oncosphere embryos emerge in the small
daily a blood vessel intestine
  

Eggs are passed in the feces

Eggs eaten by pigs (intermediate host)

Six-hooked embryo (oncosphere)
emerges from each egg in pig’s intestine

Embryos burrow into blood vessel and
carried to skeletal muscle

Develop into cysticerci in muscle

Eaten by human (definitive host)
disseminate to many organs, especially the migrate primarily to the liver but also to
eyes and brain the lungs, bones, and brain
 
encyst to form cysticerci Embryos develop into large fluid-filled hydatid

cysts, the inner germinal layer of which
cysticercosis generates many protoscoleces within “brood
capsules.”
Living cysticerci do not cause
inflammation Cyst acts as a space-occupying lesion
Cysticerci can become space- Cyst fluid contains parasite antigens,
occupying lesions in the brain which can sensitize the host.

70
71
 Praziquantel

Albendazole

Praziquantel

Praziquantel
Praziquantel

CESTODES OF MINOR IMPORTANCE

Echinococcus multilocularis
• Definitive hosts: FOXES
• Intermediate host: RODENTS
• Transmission: accidental ingestion of food
contaminated with fox feces
• larvae form multiloculated cysts (honeycomb
vesicles)
• Treatment: ALBENDAZOLE; surgical cyst removal
Hymenolepsis nana Hymenolepsis diminuta Dipylidium caninum
• Dwarf tapeworm • Rat tapeworm • most common tapeworm of dogs and cats
• most frequently found tapeworm in developed • Transmission: ingestion of RAT FLEA cysticercoid • Transmission: ingestion of DOG OR CAT FLEAS
countries larvae carrying cysticerci
• Ingestion of cysticercoid larvae from infected • Accidental parasite • Diagnosis: “barrel-shaped” proglottids in stools
RICE or FLOUR BEATLE • Drug-of-choice: NICLOSAMIDE
• eggs are directly infectious for humans
• eggs either pass in the stool or can reinfect the
small intestine (autoinfection)
• Eggs: 8-10 polar filaments and six-hooked larva
• Treatment: PRAZIQUANTEL

72
 TREMATODES ARTHROPRODS OF MEDICAL IMPORTANCE

▫ Phylum: Platyhelminthes Organism Scientific Name Disease Features

▫ Flattened, leaf-shaped or cylindrical worms (Schistosoma) Lice Pediculus humanus Pruritus of the scalp or trunk
▫ Unsegmented Nits seen of hair shaft
▫ Hermaphroditic / Monoecious except SCHISTOSOMA Treatment: topical ivermectin lotion, lindane, and malathion
▫ All flukes are transmitted by ingestion of METACERCARIA except SCHISTOSOMA which is Phthirus pubis Pruritus in pubic area
transmitted by skin penetration of CERCARIA. Nits seen on hair shaft
▫ All fluke eggs are operculated except SCHISTOSOMA. Flies Dermatobia hominis Pruritic, painful, and erythematous nodule
Larva may be seen emerging from nodule
SPECIES: Pruritic, erythematous wheal
Bedbugs Cimex lectularius
▫ Paragonimus (lung fluke)
Mites Sarcoptes scabei Pruritic, erythematous papules and linear tracks
▫ Schistosoma (blood fluke) Treatment: permethrin cream, washing/drying
▫ Fasciolopsis all clothing/bedding, treat close contacts
▫ Echinostoma Ticks Dermacentor Ascending paralysis
Small intestinal flukes
▫ Metagonimus
▫ Heterophyes
 Permethrin: neuronal membrane depolarization via Na+ channels
▫ Fasciola
 Malathion: acetylcholinesterase inhibitor
▫ Clonorchis Liver flukes
 Lindane: blocks GABA channels → neurotoxicity
▫ Opistorchis
▫ Eurytrema pancreaticum (pancreatic fluke)
▫ Gastrodiscoides (large intestinal fluke)

CLASSIFICATION OF TREMATODE EGGS

LARGE UNEMBRYONATED MEDIUM, UNEMBRYONATED SMALL / MINUTE, EMBRYONATED
▫ Echinostoma ▫ Paragonimus ▫ Clonorchis
▫ Fasciolopsis ▫ Heterophyes
▫ Fasciola ▫ Opisthorchis
▫ Metagonimus

CLASSIFICATION OF FLUKES ACCORDING TO SECOND INTERMEDIATE HOST

WATER PLANT- SNAIL-BORNE
ANT-BORNE FISH-BORNE
BORNE (MOLLUSKS)
▫ Faciolopsis buski ▫ Eurythrema ▫ Echinostoma ▫ Clonorchis sinensis
▫ Fasciola hepatica pancreaticum ilocanum ▫ Heterophyes heterophyes
▫ Opisthorchis spp.
▫ Metagonimus yokogawai

73
 TREMATODES / FLUKES
Parasite Biology /
Characteristics
Intermediate Host
Infective stage
Mode of Transmission
Stage in Humans
Associated with Disease
Sites Affected
Spectrum of Disease
Diagnostic Test
Diagnostic Features of Eggs
Treatment
Others
Schistosoma japonicum S. mansoni S. haematobium Paragonimus westermani Clonorchis sinensis
 Oriental fluke; Blood flukes  Japanese lung fluke  Chinese liver fluke / Oriental liver fluke
 Reside in the mesenteric and portal veins  Hermaprodite  Hermaprodite
 Adult schistosomes exist as separate sexes (other trematodes are hermaphrodite)
 Evade host defenses by coating themselves with host antigens
 Can cause schistosomiasis (aka bilharzias, bilharziasis, or snail fever)
Snail: Snail: Snail: Snail: Antemelania asperata Snail: Parafossarulus
Oncomelania hupensis quadrasi Biomphalaria glabrata Bulinus truncatus Mountain crab: Sundathelphusa philippina Fish: Cyprinidae
CERCARIAE LARVAE (metacercariae) LARVAE (metacercariae)
SKIN PENETRATION BY CERCARIAE INGESTION of raw crabmeat/crayfish INGESTION of undercooked fish
Adult flukes living in mesenteric or bladder veins lay eggs that cause granulomas Adult flukes live in the lungs Adult flukes live in the liver
Veins of small intestine, liver Veins of colon Veins of urinary bladder Lung Liver, especially the common bile duct
Intestinal Schistosomiasis Urinary Schistosomiasis Paragonimiasis Clonorchiasis
ACUTE SCHISTOSOMIASIS:  Within the lung, the worms exist in a fibrous  Inflammatory response can cause
 Cercarial dermatitis (swimmer’s itch) capsule that communicates with a bronchiole → hyperplasia and fibrosis of the biliary
 Katayama fever: systemic hypersensitivity; serum sickness-like syndrome provokes a granulomatous reaction tract
CHRONIC SCHISTOSOMIASIS  Secondary bacterial infection frequently occurs
 Main symptom: chronic cough with bloody ACUTE DISEASE:
 Pseudopolyps in the colon  Painless hematuria and  Fever, eosinophilia, lymphadenopathy,
 Liver granulomas (due to delayed hypersensitivity) lead to sputum
fibrosis of the bladder tender hepatomegaly
 CXR: ring shadow opacity
presinusoidal obstruction, hepatomegaly, and portal  Hydronephrosis
 Closely resembles tuberculosis CHRONIC DISEASE:
hypertension  Associated with squamous
 Hepatobiliary disease
 gastrointestinal hemorrhage, massive splenomegaly cell carcinoma of the  Pancreatitis
 Liver UTZ: clay pipestem fibrosis with lacelike pattern bladder  Cholangiocarcinoma (Klatskin tumor)
 MCC of death: exsanguination from ruptured esophageal
 Neurocirculatory dystonia
varices
Fecalysis (Kato-Katz technique): demonstration of parasite eggs 3% NaOH preparation Direct fecal smear
Circumoval precipitin test (COPT): detects circulating schistosome antigen Potassium permanganate stain
Rectal imprint: biopsy of rectal tissue with the aid of proctoscopy - showing melon-like ridges with
abopercular protuberance
Large, prominent Operculated / unembryonated egg in Operculated / embryonated egg in
Small lateral spine (‘knob’) Large terminal spine
lateral spine sputum or feces feces
PRAZIQUANTEL PRAZIQUANTEL PRAZIQUANTEL
AREAS OF ENDEMICITY: Sorsogon, Samar, Leyte, Oriental Mindoro, Bohol, ASIAN LIVER FLUKES:
all of Mindanao EXCEPT Misamis Oriental • Clonorchis sinensis
• Opistorchis viverrini (Southeast Asian liver fluke)
The single most important epidemiological factor in schistosomiasis is human waste in water
containing the intermediate host.
74
TREMATODES/FLUKES OF MINOR IMPORTANCE
Fasciola hepatica
 sheep liver fluke
 Humans are infected by eating watercress (or other aquatic plants)
 Symptoms are due primarily to the presence of the adult worm in the
biliary tract.
 In early infection, right-upper-quadrant pain, fever, and hepatomegaly
can occur, but most infections are asymptomatic.
 Months or years later, obstructive jaundice can occur.
 Halzoun is a painful pharyngitis caused by the presence of adult flukes
on the posterior pharyngeal wall.
 The drug of choice is triclabendazole.
Schistosoma
Fasciolopsis buski Heterophyes heterophyes
 giant intestinal fluke  intestinal parasite of people living in Africa, the Middle East, and Asia
 intestinal parasite of humans and pigs that is endemic to Asia and India. who are infected by eating raw fish containing cysts
 Humans are infected by eating aquatic vegetation that carries the  Pathologic findings are due to inflammation of the intestinal
cysts. epithelium as a result of the presence of the adult flukes.
 Pathologic findings are due to damage of the intestinal mucosa by  Mimics peptic ulcer disease
the adult fluke.  Praziquantel is the treatment of choice.
 Most infections are asymptomatic, but ulceration, abscess
formation, and hemorrhage can occur.
 Gland abscesses
 Worm intoxication: anasarca and coma resulting from
accumulation of toxins
 Praziquantel is the treatment of choice.
Paragonimus
75
Clonorchis Ascaris

76
 Necator & Trichuris
Ancylostoma

lemon-shaped or
barrel-shaped eggs
with bipolar plugs /
football-shaped eggs

77
NEMATODES Necator americanus Strongyloides
Ascaris lumbricoides Trichuris trichiura Enterobius vermicularis Capillaria philippinensis
Ancylostoma duodenale stercoralis
Common Name or Giant Roundworm / Ascariasis Hookworm Whipworm Pinworm / Seatworm / Strongyloidiasis Pudoc Worm / Capillariasis
Disease Miners’ anemia, “tunnel disease”, Wakana disease, Mystery Disease / Wasting Disease
Enterobiasis / Oxyuriasis
“brickmaker’s anemia” “Egyptian chlorosis”
Parasite Biology /  Most common and largest nematode  Soil-transmitted helminth (STH)  Soil-transmitted helminth  Soil-transmitted helminth  Soil-transmitted helminth  intestinal nematode
Characteristics  Soil-transmitted helminth (STH)  Blood-sucking nematodes  Life cycle is confined to humans  Facultative parasites  only nematode whose life cycle
 Differentiated based on character of buccal  MC STH in developed countries  only helminth that causes involves a migratory bird
spears of filariform larvae → a cosmopolitan worm greater pathology in AIDS
patients
Habitat Small intestine Small intestine Large intestine Large intestine Small intestine Small intestine
Transmission Ingestion of embryonated eggs Skin penetration by filariform larva (L3) Ingestion of embryonated eggs Ingestion of embryonated eggs Skin penetration by filariform ingestion of infected fish with
Inhalation of eggs larva (L3) L3 larvae
Infective Stage Embryonated egg L3 / Filariform larva Embryonated egg Embryonated egg L3 / Filariform larva L3 larvae
Diagnostic Stage Fertilized egg Eggs in feces Unembryonated egg Eggs on perianal folds Rhabtidiform (L1) Unembryonated egg
Diagnostic Test Direct fecal smear Direct fecal smear Direct fecal smear Graham’s scotch/cellulose Harada-Mori culture Direct fecal smear
Kato-katz technique Kato-katz technique Kato-katz technique tape test Kato-katz technique
Harada-Mori culture - lemon-shaped or barrel- (distinguished by their - Peanut-shaped eggs with
- D-shaped ovum with thin
shaped eggs with bipolar prominent genital primordium flattened bipolar plugs
colorless cell wall
plugs / football-shaped eggs and a pointed tail)
Pathogenesis  Major damage occurs during larval  The major damage is due to the loss of  Burrow their hairlike anterior  Female releases thousands of  Larvae penetrate intestinal  Embryonated eggs can cause
migration blood at the site of attachment in the ends into the intestinal mucosa fertilized eggs on perianal skin wall directly without leaving autoinfection and
 Principal site of tissue reaction is the small intestine (0.1-0.3 mL/worm/day)  Does NOT cause significant - Eggs develop into larvae, host and migrate to the lungs hyperinfection
lungs, where inflammation with an  Blood is consumed by the worm and oozes anemia causing anal pruritus (autoinfection)  ulcerative and compressive
eosinophilic exudate occurs from the site in response to an  Autoinfection can occur degeneration of enterocytes →
 Heavy worm burden → malnutrition anticoagulant made by the worm. severe malnutrition
Spectrum of LUNG PHASE: CUTANEOUS PHASE:  Diarrhea  Pruritus ani CUTANEOUS PHASE: ACUTE DISEASE:
Disease  L3→L5  Penetration of L3 to the skin  Rectal prolapse (from  Eosinophilic enterocolitis  Penetration of L3 to the skin  Borborygmi
 Hypersensitivity pneumonitis  Ground itch increased peristalsis to expel the  Vulvovaginitis  Acute: Ground itch  Fever, abdominal pain,
(Loeffler’s Syndrome)  Cutaneous larva migrans (creeping worms)  Salpingitis  Chronic: serpiginous track eosinophilia
INTESTINAL PHASE: eruption)  Appendicitis (oxyuriasis) (larva currens)
 L5 → adult worms LUNG PHASE: LUNG PHASE: CHRONIC DISEASE:
 Acute intestinal obstruction  Lung migration of L3 (no development)  Lung migration of L3  Chronic watery diarrhea
 Malabsorption syndrome  Simple lung eosinophilia (Loeffler’s  Acute: Loeffler’s syndrome  Edema, wasting
 Nutrient deficiencies syndrome)  Chronic: Paradoxical asthma  Protein-losing enteropathy
WANDERING WORMS: INTESTINAL PHASE: INTESTINAL PHASE:  hypogammaglobulinemia
 Due to erratic behavior of adult worms  L3 → L5  Mild watery diarrhea
 Hepatobiliary ascariasis  Up to 200mL of blood may be lost per day  burrowing into the mucosa and
 Pancreatitis, appendicitis  Iron-deficiency (microcytic submucosa → ulceration and
hypochromic) anemia → weakness and sloughing → duodenitis
pallor DISSEMINATED
 Protein malnutrition (hypoalbuminemia) STRONGYLOIDIASIS:
 Hyperinfection syndrome
(in immunocompromised)
Treatment Albendazole (has greater larvicidal Albendazole Mebendazole Pyrantel Pamoate Ivermectin Albendazole
activity than mebendazole)

78
 Strongyloides

Enterobius

D-shaped ovum

79
 Wuchereria

Capillaria

80
81
82
83
 NEMATODES OF MINOR IMPORTANCE

Ancylostoma caninum, Angiostronglyus

Onchocerca volvulus Loa loa Dracunculus medinensis Toxocara canis Anisakis simplex
A. braziliense cantonensis
 Transmitted by female  African eye worm  Guinea fire worm  Dog ascaris  Dog and cat hookworm  Transmitted in  Zoonotic roundworms
blackfly (Simulium)  Transmitted by deer fly or  Transmitted when copepods  Visceral larva migrans  Creeping eruptions undercooked seafoods  Transmitted in raw
 Clinical findings: mango fly (Chryops) are swallowed in water  Ocular toxocariasis (cutaneous larva  Eosinophilic meningitis seafoods
- Dermal nodules  Loaiasis characterized by  Clinical findings: - Ocular larva migrans migrans)  Most common cause of  Causes eosinophilic
- Hanging groin deformity - Subcutaneous edema - Pruritic painful papule - Uveitis parasitic meningitis gastroenteritis
- Lizard skin (calabar swellings) - Live worm in skin ulcer - Endophthalmitis
- River blindness - Worm crawling across
 DOC: Ivermectin the conjunctiva
- Lysis of worms →  DOC: Diethylcarbamazine
Mazzotti hypersensitivity
reaction

Major References:
Jawetz, Melnick and Adelbergs Medical Microbiology 27th ed
Review of Medical Microbiology and Immunology 13th ed
Philippine Textbook of Medical Parasitology by Vicente Y. Belizario and Winifreda U. De Leon
Online: https://www.cdc.gov/

Supplemental References (for memory aids):

Topnotch Med Board Prep Microbiology Reviewer by Pacifico Eric E. Calderon
First Aid for the USMLE Step 1 2018
First Aid for the USMLE Step 2 CK
USMLE Road Map: Pharmacology

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