Cm: DIAGNOSIS Brucellosis Q Specimens: Blood, bone marrow, etc. Q Blood culture by: » Castaneda’s biphasic media (BHI broth/agar) » Automated techniques such as BACTEC or BacT/ALERT, O Culture smear and motility testing: Reveals non-motile gram-negative coccabacilli © Identification: By automated identification systems such as MALDI-TOF or VITEK; or by conventional biochemical tests O Serological tests (antibody detection) » Standard agglutination test (SAT)—detects IgM * Tests to detect IgG antibody—2ME test, ELISA, Q Molecular method: PCR detecting rrs-rr! gene, Omp2 gene, protein BCSP31 and IS711 insertion sequence.per year in temperate climates to 10-100/100,000 in twopical countries. During outbreak the incidence may reach over 100/100,000 © Global distribution: Leptospirosis is worldwide in distribution. About one million severe cases of human leptospirosis occur every year, with a ease-fatality rate BORATORY DIAGNOSI Specimens: CSF, blood and urine Microscopy Dark ground or phase contrast microscope or silver impreg- ration staining: Reveals spirally coiled bacili (tightly and CHAPTER 32 @ Miscellaneous Bacterial Bloodstream Infections inal Fever + Meningitis findings + Myalgie “+ Uveitis optic neuris 1 Headache hovered * Conjurctvalsuftuston Rash 4 Abomin! pain + Fever 1 Pharyngeal erythema + Peripheral neuropathy suthout exudates «= Vomiting Isolation From bloodand CSF From Une Serum om Present ‘ibis blots Refractory toteatment com. regularly colle), with characteristic hooked ends lke umbrella hand rotation Culture condition: 30° for 4-6 weeks |G. Medium: EMH medium, Korthof's and Fletchers media ‘Animal inoculation: Samples are inoculated inte hamsters and young guinea pigs Serology for antibody detection 1 Genus specific tests: Macroscopic slide agglutination test, tex agglutination test EUSA, ICT 12 Serovar specific tert Microscopic agglutination test Molecular methods: 1 PCR detecting tS or 235 RNA or'51533 genes 1B PCR-AFLP and PEGE: to detect genomospecies "Nonspecific findings: altered renal and liver function tests Coes High grade fever * Liverjaundice (5-109) and raised liver enzymes + Hemonhages: > Pulmonary hemorrhage emonthage + Kadrey—Raised serum wea and creatinine and renal fare ‘Blood and CSF Urine Absent Present Susceptibletoannbiotcs _Refractoryto treatment Culture tsolation Culture technique is laborious, technically demanding and ‘time-consuming; therefore not routinely used for diagnosis. Culture condition: Leptospira is obligate aerobe and slow growing. Cultures should be incubated at 30°C for 4-6 weeks. Culture fluid should be examined under dark. ground microscope for the presence of eptospires Culture media: As Leptospira is highly fastidious, requires enriched media such as—(1) EMJH liquid ‘medium (Ellinghausen, McCullough, Johnson, Harris), (2) Korthof’s medium, and (3) Fletcher's semisolid ‘medium Serology for Antibody Detection 4 IgM antibodies appear early within one week ofillness, reach peak levels in third or fourth week and thenCHAPTER33 © HIVAIDS ‘outcome s invariably fatal, nocure or vaccine s available so far, and in the majority, the transmission is through sexual contact, Hence, individuals known to be HIV infected are stigmatized and develop a fear of being discriminated and socially outcasted. Therefore, the following care should be taken ($Cs) while performing the test for HIV. ‘© Consent in written format should be taken before the testis done, The patient should be explained about the ‘nature ofthe test being performed. Confidentiality ofa positive test result isa must Patient name or the word “HIV positive should not be written ‘on the report form © Counseling should be provided to motivate the indi ‘vidual to tell the spouse/family and induce behavioral change. Antibody Detection Detection of anti-HIV antibodies is the mains dlagnosis of HIV. Tests to detect specific HIV antibodies. can be classified into: Screening Assays Screening assays usually take less time (2-3 hours for ELISA, less than 30 minutes for rapid/simple test): © High sensitivity and specificity: NACO recommends ‘the use of ELISA and rapid kits which have a sensitivity ‘of 299.5% and a specificity of 298% Should be confirmed: Results ofa single screening test should never be used as the inal interpretation of HIV status as false positive results oF technical errors can ‘occur: Its always subjected to confirmatory tests ‘© Antigens used in most othe screening tess are: ‘© HIV-1 specific (p24, gp 120, gp160, gp4l) = HIV-2 specific gp36. ‘© They detect HIV-1 and 2 either separately or together. ELISA (Enzyme-linked Immunosorbant Assay) ELISA isthe most commonly performed screening test at blood banks and tertiary care sites. Iis easy to perform, adaptable to large number of samples. tis sensitive, specific, and cost effective, ELISA kits: Most ofthe currently available ELISA kits are coftwo types: Grd generation ELISA that uses recombinant and/or synthetic peptides as antigen to detect HIV antibodies ' dh generation ELISA that detects both HIV antibodies ‘and 24 antigen by using combination of recombinant synthetic peptides as well as monoclonal antibodies re spectively. Itreduces the window period considerably. Note: Older ELISA kits based on crude HIV antigen (first apid/Simple Test ‘These assays have heen developed for ease of performance land quick results. They generally requite less than 30 minutes to perform and do not require special equipment. ‘They are the most commonly used tests in India They work ‘on various principles such as: Dot blot assays (or Immunoconcentration oF flow through method, eg Tridot test, se Fig. 12.13) # Immunochromatography (or ICT, lateral ow assay) + Particle agglutination assay (using late, gelatin, RBCs) ‘ Dipstck/Comb ests (Enzyme immune assay-based tess), Supplemental Tests “These assays are highly specificantibody detection methods, hence used for validation of postive results of screening. tests. They are expensive, labor intensive, need expertise 10 interpret, and mayalso giveequivocal/indeterminate results. Wester Blot tis the most commonly used supplemental test available and is also recommended by NACO. It works on the prineiple of immunoblot technique (éeseribed in Chapter 12) © It detects individual antibodies in serum separately ins various antigenic fragments of HIV (Fig. 33.) = Anubody to gag gene products (p55, p40, p24, p18) 1 Antibody to pol gene products (p65/66, p35/S1, p31) ‘= Antibody to env gene products (gp 120, gp160, gpa) ‘© Theamtigen antibody complexes appearas distinct bands ‘on nitrocellulose strip + Reactive results ae interpreted as per: = WHO criteria: presence of at least two envelope bbands (out of gp120, 2p160 oF gpa) with or without agor pol bands = CDCeniteria presence of any two; out of p24, gp120, 160 and gp bands Detection of p24 Core Antigen ‘The p24 antigen becomes detectable alter 12-26 days of Infection and lasts for 3-4 weeks thereafter, Again. * clevated during the late advanced stage of AIDS. detected by Ath generation ELISA (described ea Tks Tess sensitive (-30%) because once tr Sn a ey i. see = is formed, i binds to the p24 protein and 1 antibody complex gets eliminated from the * Recently, antigendissaciation assay hasbeen, ‘that involves pretreatment of serum to an ag,Pee eee Les Malaria Microscopic tests: @ Peripheral blood smear—gold standard » Thick smear—more sensitive » Thin smear—speciation can be done based on the following features: # =P vivax—amoeboid ring form and schizont ¢ P falciparum—ring forms (multiple ring form, accole form, headphone shaped ring forms), banana shaped gametocytes ¢ P.malariae—band forms # Povale—enlarged fimbriated oval RBC with ring forms Q Fluorescence microscopy (Kawamoto’s technique) Q@ Quantitative buffy coat examination—parasitized RBCs appear as brilliant green dots. Nonmicroscopic tests: Q Antigen detection tests (RDOTs) or |CTs—detect pan malarial Ag (LDH, aldolase), falciparum specific Ag (HRP-II) Q Culture—RPMI 1640 medium QO Molecular diagnosis—PCR taraeting 1&5 rONA.eee Visceral leishmaniasis Q Microscopy—Giemsa staining, detects LD bodies (i.e. macrophage filled with amastigote forms) » Splenic aspiration: Most sensitive > Bone marrow aspiration: Most common specimen >» Lymph node aspiration > Liver biopsy > Peripheral blood smear (in HIV-infected people) » Biopsy of various organs (in HIV-infected people) G@ Culture (detects promastigotes)—useful for species identification and drug sensitivity testing » NNN medium > Schneider's liquid medium Q Antibody detection in serum » ELISA, IFA and direct agglutination test > ICT using rk39 or rKE16 antigens Q Antigen detection—carbohydrate antigen in the urine (latex agglutination test) G Molecular method—PCR, real-time PCR detecting specific kinetoplast (mitochondrial) DNA. @ Leishmanin test (montenegro test)—indicates good CMI (DTH reaction); positive in all stages, except active VL and diffuse CL Q Animal inoculation—golden hamster O Nonspecific tests to detect: » Hypergammaglobulinemia—by Napier's aldehyde test and Chopra's antimony test » Pancytopenia—by complete blood countQImmcnaars ABORATORY DIAGNOSIS Bancroftian filariasis » W bancrofti—tail tip pointed, free of nuclei » B. malayi—tail tip blunt, nuclei extended upto tail tip Q Antigen detection (ELISA, ICT)— detects Ag by using mAb to 0g4C3 Ag and AD12 Ag Q Antibody detection ® Flow-through assay using WbSXP-1 Ag » Luciferase immunoprecipitation system using Wb1 23 Ag Q Imaging methods—filarial dance sign in USG, indicates serpentine movement of adult worms in lymphatics Q Molecular methods—real-time PCR detecting genes such as Sspl repeat, pWb12 repeat, pWb-35, etc, Q Other methods—eosinophilia, elevated IgE.LABORATORY DIAGNOSIS a Qa a Ooo Direct microscopy: Gram-positive oval budding yeast cells with pseudohyphae Culture on SDA: Produces creamy white and pasty colonies Tests for species identification: » Germ tube test (positive for C. albicans) > Dalmau plate culture for chlamydospore production » Growth on CHROMagar Growth at 45°C (positive for C. albicans) Carbohydrate assimilation test and carbohydrate fermen- tation test + Automated systems such as MALDI-TOF and VITEK > Molecular methods such as PCR. Immunodiagnosis: > Antibody detection against cell wall mannan antigen > Antigen detection suchas cell wall mannan and cytoplasmic antigens. Enzyme detection, €.9- enolase Detection of metabolites, €.9. mannitol and arabinitol -d-Glucan assay: marker of invasive fungal infection. 2 eee: Miannncit) Pe eee hm ees Escherichia coli Infections Q Sample collection: Depends on the site of infection—urine, stool, pus, wound swab, blood, CSF, etc. QO Direct smear: Gram-negative bacilli, and pus cells O Culture: » Blood agar: Gray, moist colonies »* MacConkey agar: Flat, pink LF colonies Q Culture smear and motility: Motile gram-negative bacilli O Identification: » Catalase positive and oxidase negative » ICUT tests: Indole (+), Citrate (-), Urease (-), TSI: A/A, gas (+), H,5 (-) » Automated systems such as MALDI-TOF or VITEK Q Antimicrobial susceptibility testing‘Shigtlossypcallyevoves through ve phases: Incubation period: it wu ats for 1-4 days 2 Inia pase Is characterize by watery dane with fever malaise, anoreia and vomiting ise of dysentery: I fs characterized by frequent pasnage of bloody muicopurulent stots with increased tenesmus and abdominal craps Endoscopy shows an edematous and hemorrhagic mucosa with weertions tnd overlying exudates, Most of the cases are sell. limiting 4. Phase of complication: [is commonly seen with children less than years age * Intestinal compliestions such as oxle megacolon, pevforations and real prolapse 1 Metabolic complications sich as hypoglycemia, Syponarenti and eon ‘syndrome of oxic encephalopathy: isa towel complcaion of gel malt at tered consciousness seizures, delirium, abaormal posturiigand cerebral edema f= Bacteremia fs rare and can lead to meningitis and pneumonia. Rarely, cases of vaginitis and eratoconjunctivite have been reported. Postinfetious phase: Patients expressing HLA-B develop an autolmmane reaction months after ‘shigellosis: characterized by reactive arth, ocular Inflammation and urethritis tts seen only after ‘flexneri inection (oecurs in 3% a ease) Epidemiology Aik factors for shigellosis include overeromdling, poor yen ad tire ha + etendsw occur as epidemics in developing counties suchas Indian subcontinent and sub-Saharan Arica © S fleaner accounts for mau number fcases (60%) Inthe developlgareas ining, whereas 5 sonnet 'Smore revlentin developed andindusialized word, sccounting for 77% ol cases =. Laboratory Diagnosis Fresh stool i the ideal specimen. Rectal swab ate not saislactor. Specimens shouldbe transported une ditely ‘seat in ransport media wich a Sachs ltedgycerl saline. ° Wet mount preparation of feces shows large numberof pus cells erythrocytes and macrophages {Culture To lab the commensal fecal specimen is Inoculated simultaneously ito ensicheent broth and selective medi Enrichment broth such as Selenite F broth, {etrathionate bro and gram-negative broth ate sed 1 Selective media such + Mildly selective media: On MacConkey agar the {row appears a transhicent and non-taciose Fermenuingpale colonies Highly selective medium con ‘concentration of tle salts a8 inhibitory agent Examples include () DEA (Deorycholate crate ‘agar producing colorless NLF colonies and ( XID agar (yon sine deoryeholate) producing red colonics without black enter + Cultaresmear and motliy testing Gram stained smear of colonies reveal shor gram-negative boc. They ae hhonmotie,noneapsulated and nonsposing © Identiieations idenication of Shigla fom colonies Ismade ether by automated identiiation systems such as VITEK: or by conventional bochemcal ests as described below ‘ Shigela is catalase postive (except Sysentriae serotype) and oxidase negative ' ICUT tests: Indole test (negative), citrate te (oeuvre), reat tet (negate) and TSI (ple gar ‘won agar) ext shows saline aid, gas absent, HS 1 All Shiela species are mannitol fermenters except Scabserteriae SECTIONS Gastrointestinal (Gt nfecions 1 Auomatedmethod, MALDI-TOF poor diferentes Sigel om cols they she the sme boom proteins. + Serotyping: Because of biochemical variations, ‘lenieation of Shiela always confirmed by side agglutination with polyvalent antisera (genus specif). “hen, the species Idemieation can be dome by usa roupspecii antisera speci or serogroup Seotypes liner each species are further detected by us pe specific antisera © Collin typingcas be done oe S sonnel * Anuinceoblal susceptibility esting done on Muller Hinton agar by dick difsion est “Treatment Unlike Ecol tardaisussalysuscepibito ont antimicrobials used for ram-neqatve cil wich as quinolones orephalosporns. SALMONELLA INFECTIONS (SALMONELLOSIS) Salmonella are antigenically complex: comprite of xx species which in tum comprise of several serotypes sed fn thee surlace antigens. The human serotypes belong to Salmaneiaeneric subspecies enterica: which can be ure vided into two cine grou |. Typhoidal salmonetiae:inclade serypes Typhand "Parayphi A,B, and C. They are restricted human pe reap ey fein relearn alySS raetene prieaty cies Ajtai 1 Incubation perio: sully lasts foe 1-t.days 2 Inia phase is characterized by watery darhea with fever malas, anoeenia anal ving 4. Phase of dysentery: Its characterized by frequent passage of bloody mucopurulent stools with tareased tenesmusand abdominal eramps. Endoscopy shows an fdematous and hemorrhage mucona, with ulcerations and overlying exudates. Most ofthe eases ar sll Teiig 4. Phase of complication: Ics commonly seen with dlildren es than 5 yearsage ‘Intestinal complications such as toxle megacolon, tnyponatemia and dehydration ‘© Fhiet syndrome ot toxic encephalopathy: Is & ‘metabole complication of shigellosis; martes ax tered consciousness, seizures delim abaormal lead to: meningitis fand pneumonia. Rarely, eases of vaginitis and eratoconjunctvit have been reported Portinfectiou Patients expressing HLA-B2 develop an autoimmune reaction months after ‘shigellosis: characterized by reactive attvits, oct inflammation and urethits Its scen only alter Sexnert infection (occurs in 3% of cases). Epidemiology Ask factors for shigellosis Include overcrowding, poor Jnylene and children less than 5 yeas 1 Tetends to occur as epidemics in developing counties uch ax Indian subcontinent and sub-Saharan ‘ica {© Slemnerlaccountsfor maximum umber ofcases 0%) Inthe developingareasincuding nd whereas S sonnet smote prevalent in developed and industalized word, sceounting oF 77% of cases Laboratory Diagnosis Fresh stool isthe ideal specimen. Rectal swabs are not satistactory Specimens shouldbe trangprted immediately fr sentin tansport media such a Sets bullered glyceral tale © Wet mount preparation offeces shows lage numberof scl erythrocytes and macrophage 4 Culture: To inhibi the commensal, foal specimen i Inoculated simultaneously ino enrichment broth and selective media Enrichment broth such tetrathionate broth and ted 1 Selective media auch as: 4 Mildly selective media: On MacConkey aga, the {growth appears ax tanshicent and non-lactose fermenting pale colonies 4 Highly selective ‘concentration of ‘gent Examples include: () DA (Deoxycholate eluate gar) producing colorless NLF colonies and (i) XLD agar (Sos ysine desycholae) producing, red colonies without black center, © Culturesmear and moti testing Gramstanedsmese ‘of colonies reveal shot, gram-negative cil hey are onmotle noncapsulaed and nonsporing ldentiicatton: Identification of Shigella rom colonies Ismade either by automated identification systems suchas VITEK; ory conventional biochemical ests described below (eptive), urease et (negative) and TSI (pe sugar ‘won aga) west shows alaline/aci, gas absent absent 1 All Shiga species are manta fermenter; except Scdysemeriae SECTIONS # Gastrointestinal (GH infections ' Awomated method, MALD-TOF poor diferentes Shigella orn E.coli as they share the same ovomnal proteins. © Serotyping: Because of biochemical variations, ‘Menufeation of Shiglia i always contrmed by aie agglutination with polyvalent antisera (genus specie) “Then, the species idenaeation can be done by using soup speciicaniser specificor serogroups Seroypes Under each species are further deveted by using pe Specific anusera + Coliein typing can be done fo 8. sonnei * Antimicrobial susceptibility testingis Jone on Mueller inion aga by disk difuion text. Treatment: Unlike F col tarda usualy susceptible to ‘mostantimicrobials used for gram-negative bacl suchas Auinolones or cephalosporins ‘SALMONELLA INFECTIONS (SALMONELLOSIS) Salmonella are antigenically complex: comprise of six species which n turn comprise of several serotypes based ‘on their surtce antigens. The human serorypes belong ‘0 Salmoneta enterica subspecies enteria; which can be further divided into two clinical groups: 1 Typholdal salmonella: Ince serotypes S Typhiand ‘Saratypht A, 8. and C. They are restited to hasan idan as aiksis alah Sucane Gade Pameerieeamene©, pseudotuberculois can be further diferentiated into ‘ix serotypes (1 to 6) based on somatic O and fagel Hantigens. Clinical Manifestations Overall, ¥ emteracolitica is more frequently reported clinically than ¥ pseudotuberculoss. © Self-limited gastroenteritis (diarthea with or without blood) occurs in younger children {Intestinal complications occur in older children, char- acterized by terminal ets (mostly in ¥ enterocltica) ‘and mesenteric adenits Patients present with acute pain ‘abdomen, may mimic pseudoappendictis ‘© Septicema: It ts seen typically in adults, characterized ‘with fever and leukocytosis. Itustally occurs patients ‘with coexisting diabetes mellitus liver disease and iron ‘overload © Postinfective phenomena in adulis) occurs commonly with ¥ enterocolitica, occursasaresultof autoimmune activity, inated by the deposition ofbacterial non-vable ‘components in joints and other sites. Manifestations inchide: * Reactive arthritis—mostly associated in persons positive for HLA-B 27 1 Bxythema nodosum: Itoceurs independently without anylinkto HLA-B27 phenotype © Graves disease—¥. enterocolitica contains an antigen slonilar to thyrold-stimulating hormone (TSH) binding site. However, whether this cross-reactivity thas any significant role in Graves’ disease remains unclear © Super antigen: Some strains of ¥. pseucdotubercutosts ‘express a super antigen mitogen, which has caused scarlet-lke fever in Russa, similar iliness in Japan (Laumi-fever) and has been inked to the pathogenesis ‘ofidiopathicacutesystemicvasculitisofchildhood called Kawasaki's disease Laboratory Diagnosis, Culture isolation © For isolation from blood: Blood culture bottles (BH broth) should beused + For isolation from lymph nodes aspirate: Culture is ‘done on conventional media (blood agar, nutrient agae ‘and MacConkey agar) = Blood agar: They produce granular translucent colonies witha beaten copper surface, non hemolytic colonies = MacConkey agar: Growth of ¥. pseudotuberculosis fs poor. 1 enterocolitica grows well and produces lactose non-fermenting pale colonies. © For isolation from feces, food oF sol: Selective media should be used, such as: = Deorycholate citrate agar = MacConkey agar 1 Yersinia CIN ager (Cefsulodin-irgasan-novobiocin} ‘Typical dark red bull’ eye appearing colonies are formed in 24 hours, ‘ Incubation: Plates should be incubated at29°Cand 37 tw diferentiate from most of the other pathogens which sgrov only at 37°C ‘¢ Cold enrichment can also be done by incubating in ‘phosphate: buffered saline at °C for 3 weeks. Identification ¥. enterocolitica and ¥. pseudotuberculosis show the following properties by which they can be differentiated from ¥, peti Differential motile: They are motile at 2°C (but not agrc) Coldenrichment:Grovthimproveson refrigeration (1°C) ‘ Automated identification systems such as MALDI-TOF ‘canals be used for accurate species identification. Serology Antibodies canbe detected by agglutination or ELISA using serorype specific O-antgen types. In ¥ pseudotubercudast {nfection, antibodies appear early during acute phase of less; whereas ¥. enterocolitica specific agglutinating antibodies are more likely tobe found in convalescent sera ersiiois Mostcasesof daa are selstingTratmentisrequredonly {orystemi fection: such asin cave of septicemia 1 Fuoroqulnoiane (ipa xacin) thi generation cephalo- ‘pois (cefotauie) aeetfectve 1 Fenterocolica stains nearly aways produce Plactamases butnet Vpseudonibeculess sans. PLESIOMONAS: Piesiomonas is an oxidase postive, motile, fermenting iram-negative bacillus, recenly has been included in the family Enterobaeterlaceae, based on DNA hybridization studies (previously lasiied under Vibrionaceae family). DP. shigllodes isthe only species. tis so named because i isamtigenically related to S. sonnei + Teis found as saprophyte in water and sol, and also as. ‘commensal in animal and rarely in human intestine ‘& Human infection: I rarely causes gastroenteritis which may be severe in immunocompromised patients. Extraintestinal manifestations include rare cases of ‘meninglis, septicemia, cellulitis and septic aris. |FECTIONS DUE TO NON-GI PATHOGENS The following are the members of Enterobacteriaceae famnly which mainly cause extraintestinal manifestations ‘nd therefore discussed inthe respective systems which they prinipally infect. © Dropathogenic E.coli (UPEC}:It accounts forthe most ‘common cause of UTI: discussed in Chapter 76Pie a A eed Chol Q Specimens: Watery stool or rectal swab (for carriers) Q Transport media: VR medium, Cary-Blair medium Q Direct microscopy » Gram-negative rods, short curved comma-shaped (fish in stream appearance) > Hanging drop-demonstrates darting motility Q Culture > Enrichment broth: Alkaline peptone water, Monsur’s taurocholate tellurite peptone water » Selective media: Bile salt agar, Monsur's GTTT agar, TCBS agar (yellow colonies) » MacConkey agar-produces translucent NLF colonies G Culture smear and motility testing—reveals > Short curved gram-negative bacilli and » Darting motility Q Identification » Catalase and oxidase positive > ICUT: Indole (+), Citrate (+/-), Urease (-), TSI:A/A, gas (-), HS (-) » String test positive > It produces hemodigestion on blood agar * Automated systems such as MALDI-TOF and VITEK Q Biotyping: To differentiate classical and El Tor Q Serogrouping: To differentiate 01 and 0139 Q Serotyping: To differentiate Ogawa, Inaba and Hikojima serotypes of serogroup 01 Q Antigen detection by cholera dipstick assay Q Molecular method—multiplex PCR detecting common diarrheal pathogens Q Antimicrobial susceptibility testing.Scceetrr Prove Ror ot ———— ‘mt pti, ee optim A ne) cider hte + maa miming pt = (rom tice te i fd Eovrot Lente Dignan ‘Tperttrmeriy dni Dignio p con maybeeahe y Nevanuate pen ase as + reenact LPS a nn. nergy ped mil ep cab a eecsnenseimaciestgemcpmaen meereerenanae ence toss ‘Bivimpede tr rete etna icese - i ea Tatami gomortomin cine (Gy San Seay ontrinpedty came ‘mosis ‘repute otic at pease * 2 Sie arpa ape wh PI Suet" *SSenecerwergtsmedcncintt * Ceorenunanan a ort mr ‘por hens maa te + Sencar 1 ht piectpapenasen ee Comune ear me te ts . eae itd wt {ett pps anne! ruins ocd ne a edema 4 mgt ee 1 a en ‘Sesto doe pl inn a ‘Stenduce nas otcans pnang Wihiarkenorebonste cherie RE epee enh a cans meer rte ences purport ‘omen get Spe i ‘ead ror am mre sone Gites acd pel dame A) Sema ‘welded bgene ee ‘ied meee ae + hay) ec IRA He * tn hare rec) oa Sova siemens‘© Pus calls or blood (RBCs) wil never be seen in stool Imleroscopy incase of glrdlsi 1 found; suggests ternative agnosis + Senay varie from 00% 1 0% with one stool and more than O% ater thre tool examination + Concentration techniques lie ain slatetoataton oe formalin ether sedimentation methods ar employed 0 Increase the chance of detection + Duodenal sampling If son! examination i nega ‘hen diet duodenal sample ke aspirates (obtained byentero-ent) or bop (done by endoscopy) sho bapreceeed «+ Permaneetstanesuch tichrome stancanbewsedo demonstatecjtsand wophozatesin sol Figs 4.116 and 120), no) Al eS 5s . %~ rg ‘ophorane Prete o rophartes nates cv stage fhe ae ‘hey ebterapeecedn the nine mou andpermnert ‘aning ban sine nau 3 ttre yng’ Spmin we. fermathapedanlteray appear aspoon oF ‘Sle shapedtrgr as 0A Bandas tO. 2 Metaychssaingletike matty 5 fic busery symmeta eas he lowing stirs (oss tons One met > ese or sucking kabel at sven surface > Fourposot apa. 1 Paot atonement om Gore cstsoashapec, measures 1-1 um inlengthand 7 ymin wth Pigeon TAO), hoya ssedinstooln bth porn get) Enterotest (or Sring Test) Iwuses a gelatin eapsul auached w a dead containing veg (153 2 One end ofthethueadisattached tthe outer aspect o + Capmle gets dimsalved in stomach plesing the thre wich eared wo the duodenur, get unfolded en takes up the dodenal samples, {in saline to release trophozoites which can be detect ‘microscopical by wet mono permanent sted sme ‘The entero test also wf for oher upper intestinal parses such a Sronglodes Cryplosporidim an ‘Histopathology \doscopy-guided duodenal biopsy tissue can be processed by touch prepartion and stained by Glema Santo demonsteate the ophozotes (Fi 45.120). Figs 4&1 1A oD: tf Gro ombla A Sane meu Bodine moun CTevome ar B. ect nmunofereence sy SECTIONS © Gastontesina(G nectionsAsh lodine mount; Fig. 45.6: Triage parasite panel, positive for C.Trichtome stained smear. Note the chromatoid body with blunt ends (arrow). E histolyticaE. dispar antigen. ‘Source: Swierceynski G, Milanesi 8. Atlas of human intestinal protazoa microscopic diagnosis. ‘Source: Alere Diagnostics. SECTIONS © Gastrointestinal (Gi) Infections Contd.. Charcot-Leyden crystals in stool: ‘they are diamonc shaped, eosinophilic breakdown products found in stoo of some cases * Moderate leucokytosis in blood. Giardia lamblia (alpha-1 giardin antigen) QE histolytica/€. dispar (29 kDa surface antigen): It cannot differentiate E. histolytica from E. dispar, as both express this antigen Intestinal amoebiasis & Cryptosporidium parvum (protein disulfide isomerase TT ctratanortis antigen) ‘Asymptomatic carriage: Treatment helps in reducing passageSECTIONS 4 Gastrointestinal (GD infections © @:6@ ‘a oa iepctinigds mates paese apap Life cycle Fig. 45.2) Hout F histolytica completes teman, Infectve form: Mature quadeinucestedcytstheinfctive form, However, immatute cysts ean also belnfecive Mode of translation: stlytca is transmated by—() {eco-oral route (most commen), by ingestion af food oF water contaminated with mature quadrinucleated et, (i) sexual (anogenital or orogenital) contac, (i) very relyby vectors (les and cockroaches may mechanically ‘wansmit he cysts fom feces and contaminate the food find wate) Development in Human Intestine ‘Seal intestine: Cyts bypass gastric juice and reach small intestine, where they undergo exeystaton, The «stl gets sey trypsin and four small wophozotes atereleated fe yee ina single host, aaa Seer eons ll pratt ; oa Ponto anon torre mote) adeventwems nancial es 9.48.2: cy of romorbo hoa © Large intestine: Trophonites reared othe lececal region of age intestine, where they multpy by binary fon, and then colonize onthe intestinal mucosa * Alter colonization, trophozoites show diferent courses Sepening on ny "Asymptomatic eyst pasters: In majority of Individuals trophozoites do not cause any lesion, transform noes andar excreted in feces = Amoebie dysentery: In some individuals, Luophovote adhere to intestinal mucosa producing Intestinal ulcers and dysentery = Invasive amoebiasis: Very rarely, rophozoites Sve inestina mucosa, gain acees to the pot veins and migrate to extainestinal sites, most ‘common ste Being ver where they cause amoebic lier abaces (Chapter 9), ‘© Encytatlon: When the intestinal esfons start healing and patent improves the trophozoites tansorm nto precjts then ito ejsts which are berated in feces Eneystation occurs only inthe large ltestine Cysts are neverformed oncethe tophozites are excrete insto0l + Oyss released in fees ean survive inthe environment sand become the infective form. Tropho2ates ae also xcreted but gelisintegrated eter nthe environment for by gasue juice when ingested ‘Virulence Factors ‘Trophozoite of E. histolytica is the invasive form and postemes many virulenee factors that play ipo Folein te pathogencia + Amoebic lectin antigen: tis 260-4Da galactose and ‘Nacryigalactosamine inababl surtace protein (Gal [NAG lectin), present onthe surface of tophoroites. I Is the principal virulence factor helps in adhesion by binding to glycoprotein receptors on large intestinal «piheium and vascular endothelin © Other virulence factors include: ‘= Amocbapore: It forms pores on the target cell 459/874 \+ Muliplestool examination and concentration techniques (Gormol-ether sedimentation) canbe fllowedto increase thedetection rate + Anal swabs (cellophane swabs used for Enterobs) can be used to collect fecal matter and is superior for the detection of eggs than nthe stool © Eggs of 7 saginata and 7 slium are morphologically similar exeeptthat eggs of Z saginata ate aca fast Table 462) ‘= Eggisround 31-48 pmsize and consistsof anembryo. with six hooklets surrounded by an embryaphore (igs 46.20 and C) ‘Eggs ae bile-stained; do not oat in saturated salt solution, © Proglottids of 1. saginata and 1: solium can be Aiferetiated by lateral branches in uterus, accessory lobe in ovary, vaginal sphincter and expulsion of segments (singly orn chain) (Table 462) + Scolex can be detected in feces very rarely. T: sollum scolexis armed with rstellum and hookles. Taenia Specific Antigen Detection in Stoo! ELISA has been developed to detect Taenia specific antigen (coproantigen) in stool by sing polylonal Taenia antibodies. ‘© Advantages: This test has many tits: = Claims more sensitive than stool examination # Can detect Zaenia carriers; useful forthe control of this zaonotie infection 1 Prognosis: It can be used for treatment follow-up; Decomesnegative after 30 daysofeffecive treatment * Disadvantage: ltcannot diferente between -saginata and .solium. ‘Molecular Methods PCR targeting mitochondrial DNA followed by sequencing is available: which can distinguish between Taenia species Erreamwent Invest aes 1 Praziquantel drug of choicel: Single dose of (10 ma/ka) highly efectve 1 Nidosomide (20) isaoeflectve but isnot widely avlabe, fevention Irtestinaltaeniasis can be prevented by: ‘Adequate cooking of bee or pork vseera © fective fecal disposal prevent infection tocatileand Pits ‘Taenia saginata asiatica (Asian Tapeworm) Misa subspecies of: saginat; causes intestinal weniass. eis morphologically similar to T. saginata except that tng sme Ames esdtcaer — Lageand + Smal and gaan ‘nengur Perera beeen Sie peel -lftnes abete ved Nohocter "tapeworm Praia Nefrol 16002000 00-1000 ens Sevan 5-20 Bean 7-13 Icaltrenches braces Lobetotorary weno aceon Tve-two bes whan tee xernorybe Vegi pints Present dosent Sxutionot—apeledsingyin Speedin chain 5-6 Somer thee segments lee — Crncecusbons Greens casos Descent tet phonic ond froedabuenot _sshimenborrdece fo 479/874 edt 31-43. Nora. 31-3pm leone = Diese (Gee btn! Convenes ens Sense Shaye Hos Dairies» Foresite toe pecs bot one F Srdlcermedtc oss Inlecte fom Lana eters + Foret ena toa teva ceo) + Fortceconee09 SS as poe “sorntces + Poycweestane oecedin ane Modeot ——_ngetonot_—_» Foresite ee eee cee eo innate + Formas) Seta er Stdwater an 90 econ Intermediate hos s pig (not cow), where eysticerci are locate primarily in the liver (notin the muscle). + Man acquires infection through ingestion of pig liver containing infected eysticerci + Human infection has been reported from Taiwan and ‘other Asian countries like Korea and China, but not reported from India, yetCCHAPTER4G @ Intestinal Helmithic infections o __ Figs 467A and: Dyin conan: A Frogs with to gertal pores amine aed B99 packets in sare mum. Morphology atu bas three morphological forms. 1, Ault worm: Long. measures up to >ISmeterswith over $000 proglods. The head/scoex bears two grooves or ova (Figs 46.84 and B) 2. Operculated eng 5, Larvae: Oceursin thre stages—fiststage(coracdium), ss te a a i ho Life cycle (Fig. 46.9) Le eee of. latum passes through thee hosts Humans tre the definitive host. There ae to imermediae Hosts frst (Cyclops and second (sh). ‘ Transmlsslon: Humans got infection by Ingestion of undercooked fish condalting third stage plorocercld larva Ginective form) ‘© Human GIT: Plerocercod lava develops into adult ‘worm in human small nestine: which sexual matures And fertilization takes place to proce eggs that are {eleased in ces (agnostic lem) + In Gyelopa: Eggs in water transform into L, larva (Coraciitum, which infects (Cyclops. n Cyclops, sed tan chs ao a Ve er Sua ; mma ait Pee fe mas coment Bees oe Fa 46.9 fe cy of Dpycboran atu, {larva developsint procercold lara, whlch infects fh © Infish 1 larva develops wo form, (plerocereoid) larva wich becomes the infective form, Clinical Features Most of D. latum infections are asymptomatic. Few Individuals deve rely acute abdominal paln due to Intestinal ‘obstrcton, cholangitis or cholecystitis * Vitamin B12 defielency: The adult worm causes Alisociaion ofthe vitamin B12dnrnsc factor complex ‘eithia the gut lumen, which leads toa decrease i bsorpton of B12 at eum 1 Vitamin 812 deficiency leads to development of "anemia tnd ote people may exit ‘neurologic sequelae ike paresthesia 1 This etlect hasbeen noted only in Scandinavias (ex: ‘lusvely in Finland), where up 10-2 of infected patients especialy the elderly, have megalobastic anemia, this may be atebuted 0 genet predispo ston ofthe individuals Epidemiology ‘Though D. latwm infection accurs worldwide; high Incdence has been reported om Scandinavia counties (uch as Russa and Heland and North Ameren D. lato {very arin india Three cates have been reported so far (Wllore 1998, Pondichery 2007 and Kaeinnagat 2011). Laboratory Diagnosis Stool examination reveals characte sometime segment of adul worm. ggsandProglotds (0. letum) age se oposite wihalnob atthethr ens 462R.nd te eggs and #2100 (pyr omblestined dortftinatuntedtokton+ Its differentiated from 7: saginata by PCR targeting ‘mitochondrial DNA followed by sequencing. HYMENOLEPIASIS Hymenolepiasis is caused by Hymenoleps nana, which is the smallest cestode (2.5-4 em in length) infecting man, thence also called as dwarf tapeworm. © Life eyele (Fig. 46.5): Man is the only host. Eggs are the infective form. Man acquires the infection by Ingestion of food and water contaminated with eggs or by autoinfection with the eggs released in thei small iestine ‘© Direct eyele: After ingestion in the small intestine ‘eggs hatch outand develop into cysticercoid larvae and subsequently into adult worms. Adult worms, ‘when fully mature undergo fertilization to produce ‘eggs that ate released in feces (diagnostic form), ggs are infective to man and the cyele continues f= Indirect cyele: Rarely, man acquires infection by accidental ingestion of rat flea containing the ‘ysticercoid larvae, which subsequently develop into adult worms and the eyele continues, Clinical manifestations: H. nana infection i usually asymptomatic When the wormburden exceeds patients develop symptoms like anorexia, abdominal pain, headache, dizziness and diarthea with mucus Epidemiology: H. nana is considered as the most common tapeworm infection throughout the world infecting 50-75 million of people. he overall preva lence ranges from 0 t0 4% with higher prevalence in children (16%) © Laboratory diagnosis: Stoo! microscopy detect the characteristic eggs confirms the diagnosis. Sto concentration ean be done ifthe egg load is ess. PVA (olyviny-alcohol) should notbe used fr preservation sit distorts the morphology. {Eggs of Wana Figs 46.68 and 8) gg sround to sighty oval in shape, 30-47 yn size 12 Tthas to membranes that surrounds an embryo wih sb hooklets Space between the two membanesisfited with thctened Hom whch four to eight polar Hamers Nowe stained (oes in stine mount the oni cestode eo hat not sane by Be when sed ‘hreagh he eine Egg re the ctv frm as wal th pret ofthe pase © Treatment: Praziquantel (25 mg/kg once) is the tueatment of choice since tacts against both the adal ‘worms and the eysticercold larvae. Nitazoxanide or hiclosamide may be used alternatively ® Prevention: Good personal hygiene and improved sanitation can conte the disease. Satan wer wih eags vo ‘Orty autantechan Cystcorenl ava ‘toes Dovtons Figs 46.68 and B: 99 oftymenolepis nana A. Schematics B.insaine mount (non bie stained). Saver Forme bay can Dna Pn, Hymenolepis diminuta Infection 1. diminuta is also called as rat tape worm. Rodents are the definitive host and insects are the intermediate hos. Human infection is rare, occurs through indirect cycle (as “described for H. nana). Eggs are larger 70-85 x 60-80 ya, ‘do not bear polar filaments and ae ile stained, DIPYLIDIUM CANINUM INFECTION D. caninum is @ common tapeworm of dogs and cats rarely infets man producing GI symptoms such as loss of appetite, diarthea pruritus an, abdominal pain, ete ‘© Host: Definitive hosts are dogs and eats (rarely men). Intermediate hosts are insects (leas) ‘Transmission: Man acquires infection by ingestion of Nea containing eystiercoid larva + Diagnosis: Fggs are detected in feces, 25-40 um size, present in groups of 15 (egg packets). Proglottids are 'ypically brre-shaped and contain two genital pores ‘hence also called as double pored tapeworm (Figs 46.7, and 8) DIPHYLLOBOTHRIASIS Diphyllobothriasis ts an intestinal parasitic infection, used by a cestode Diphyllobothrium latum, aso known 4 fish tapeworm Is the largest known parasite found in ‘human intestine,Laboratory Diagnosis tne egpenbncd ata mioncen ont ‘14s the most pathogens species among the schistosomnes Steet istered nti | Hare chs cs Ba ce ee = - eee lienioey Spain who beppnicans ‘Japancum nectn oscars commonly in Cin, _ inate Manan doa eft, ‘nda un Pipes icra apse 1S Cahienlsyeasafaeaecomment ated, | mo ceney paginas ‘Nocameahatbeentepoed om indoor a esas ase, Pathogenesis and lel eats Aa ye ted wrt of en gp dose by | mes a aa Sree enclaves “ ‘pecenai Memetceenpentn, FASCIOLOPSUSIS SS VSS aires owen ve eae Simtemtececucrenanmncrenit [ntl sarcoma oes aaa sauansas er eehea [te atceoetgs sersvene temas Sees Ss nieenacd es Metal anaemic re epee ae Sem cantas egaemrcasornaee cere cet ne rete” eaten meee noe to meal = eae men, haere peter eee nent Sathana feces | howeiiaweay {aboratry agro festa Pear ge, 1 rd de rns at Ct eT tec ry Teed of ul alr w the emt Serie mieganse amnatines | (ro Saemomy noaned sont 2h pecierccmrratencnatcamunry | SMGRguaene tenant Sn dn aeeecererceretas "tee at Begin daponmetndspcclrsapmiam * Mite Geeta ee ‘© Pyrosequencingasszyhas been designed wdeteetDNA HEM the metacercara larvae, oa ipaman aea hes Pytognas «+ Mapes made, te map al atrncs de he umate ad (mince arnectnsng tree inet Semen hein OT pes dloce gers cess * Upc poate naan ememcegierige ieyiininioonient eves win mw onda Resear ater usany se * ist yen ‘inetomperth sd dapantc ey ny mye SCOTTI sirosentinten* nn rat ees Pasiuni ger 0 motion edo mange, | * Mu vce 7 7 See ae Laboratory Diagnosis 17'S tnerelanm rnin endemic Ate cases Detection tlre ramr of apron a ‘Satweraros mens peace pohae denn Fn ‘muna an secon Samentctons* Earrelag(0-10pmss-mse operted ¢ Simetmgiiccon cumin isongavertnl "tie aie morhlseay sr ta EecrtataedondComeds Caney teenies PhotCCHAPTER46 4 Intestinal the eggshell) n warm (25°C) and moist envionment Embryonated eggs are infective to man and thus the Me eyete continues, Pathogenicity and Clinical Feature Incubation period varies from 701090 days. Most infected Individuals are axymptomati, with or without having eosinophil 1m people with heavy ineetlons: Adult female worms get buted in the large intestinal mucosa, that leads to: ‘Mechanical distortion: Leadingtofnflamed, edematous, and fable mucosa + Allergic response by the host: ‘macrophagestnfitratein he tumor necrosis factor-a (TNF-a) Common manifestations Include: ‘Abdominal pain anorexia, et. ‘ Trichurts dysentery syndrome—bloody oF mucoid area resembling inilanmatory bowel disease + londeficieney anemia—occutsasa result of blond loss; not due to blood ingestion a seen in bookworm + Recurtent retal prolapse-oceurs due to heavy worm loed inthe recur + Malnutrito tn Large number of opiathat produce ap pred cognitive function ~dueto the release of ant Inflammatory eyokines induced by Trichuris species growth retardation and Laboratory Diagnosis Stool Examination Stool examination scared outeltherby direct wet mount following concentration of the stool, which reveals ‘characteristic egg and occasionally adult worm, Single ‘ool specimen suffice for diagnos of symptomati ases (Figs 46-194 and B) as the level of egg Output Is ‘usually high o lige 46190 ae chr thre R {hchurtichira eggs and adult worm) age Monae 0 22 jm, bal shaped wh mucus plage 2 the end fags ate ble aned and Post im stud sk Solaon i 4619) {Whip shaped eda worms of 3-5 cm long, we caso, teen on protocopy ig 46198. Aner te nh, fairl, coed Oe tope of whip and porter wo Rs ‘hovtand th (Other Findings + Peripher! blood eosinophilia (<15%) + Increased seni ig level 2 Mabendazol'00 mg onc) or albendazole 40019 day for ‘vee doses sale and moderately eflecive for treatment, 2 ermectin (200 mag ey or vee doses) ho ae but huni Prevention Trichurlasis can be prevented by improved personal Iysiene proper disposal of feces and esproved nuriton ENTEROBIASIS Enteroblasis 1s @ common parasite Infection in children caused by the intestinal nematode, Entrobius bermiciaris. 1s als called as phawore or threadworm Infection (as the adult worm of Enterobiu i smal, we and threadtke), Epidemiology Globally, around 209 million people ate infected by pinwors; mostcammon age grat being schoolchildren ‘2 Deoplecarty the fection for years together due o auto Intecive cycles {thas been sald that: "You had de injection as hid, youwhave st now and you wigan et when ou have children” Factors promoting infection: Overcrowding and Impatred hygiene, poor personal care (oa biting oF Inadequate hand washing), Lifecycle (Fig. 46.18) Humans ace the only host. Embryonated eggs are infective ' Mode of transnision: infection occurs via ‘= Autolnfectlon: It is of two typer—(i) exogenous ‘autoinfection, by tansterting eggs 40 the mouth ‘with hands that have scratched the perianal trea, (i) endogenous autoinfcton, by retrograde ‘migration ofthe larva hatched from the eggs nthe perianal ki,‘agra rearation cise HBsAg: First marker to appear; elevated in acute, chronic orin carriers » HBeAg: Indicates active viral replication and high infectivity » HBcAg: Not detectable in serum; can be detected in hepatocytes by immunofluorescence test Q Antibody markers: Anti-HBs, Anti-HBe and Anti-HBc » Anti-HBc Ab: IgM indicates acute hepatitis and IgG appears in chronic hepatitis or carriers or after recovery > Anti-HBs Ab: Marker of recovery or vaccination > Anti-HBe Ab: Indicates low viral replication and low infectivity Q Molecular markers: HBV DNA detection > Indicates active viral replication and high infectivity > Viral DNA load helps in monitoring treatment response Q Non-specific markers: Elevated liver enzymes and serum bilirubin; indicates clinically active infection.= Presence of immunosuppression. Treatment of Te UAE Amoebicliverabscess trophozoites to eradicate t Q Microscopy—detects trophozoites (<25% sensitive) O Tissue ag 0 Antigen detection (in serum, liver pus and saliva}—by ELISA days); ort (170-KDA of lectin Ag) 2 Luminal O Antibody detection—ELISA (Ab to 170-KDA lectin Ag) paromom 0 Molecular diagnosis—nested multiplex PCR and real-time Aspiration PCR (detecting185 rRNA) Aspiration 0 o Ufssenasterhy eet the site of abscess and its ding improvemenfollowed by G5 (cattle strain). ea Umar) Hydatid disease Hydatid fluid microscopy (direct mount or staining with Histological examination (H & E}—demonstrates cyst wall and attached brood capsules 9 Antibody detection—ELISA (using B2t antigen), DIGFA (dot immunogold filtration assay) and western blot © Imaging methods —X-ray, USG (demonstrates Water lily sign), CT scan, MRI Q Molecular methods—PCR, PCR-RFLP and molecular typing (10 genotypes, most common in India is type 1) Skin test (Casoni test}—demonstrates type | hypersensitivity reaction (obsolete now). Laboratory Diagnosis= oo re J Figs 49.70 andB: Saline mount showing operculated e998 of ‘A Foscila hepatica B.Clonorcis or Opisthorchis Sure 00 nae Libres er Oss Corto and Prevention ‘ema wen sermon + Molecular methods: Various PCR-based methods are available to detect F hepatica specific genes in stool Specimens © Imaging methods like ultrasound, CT scan or MRI can bbe employed to detect the lesions in the liver. Fasciola gigantica E gigantica is closely elated to F hepatica. isa common parasite of herbivores ike catle; human infection is rare. Eggs of F gigantica are morphologically similar to that of, F hepatica and but larger in size. Rest of life cycle, clinical feature, laboratory diagnosis and treatment are similar to that of F gigantica, Clonorchiasis and Opisthorchiasis Clonorchis sinensis (called as Chinese or oriental liver fluke) is found primarily in Eastern Asia lke China, Korea, Japan and Malaysia. Opisthorchis viverrinthas been reported from Southeast Asia, mainly rom Laos, Thailand and Cambodia. In India, ‘they are not reported yet. Opisthorchisflineus (cat liver fluke) is another species, that is limited to Central and astern Europe, Russia and Kazakhstan. Ginicol Features In chronic infection with heavy worm burden, they cause ‘mechanical obstruction of the bile duct and irritation due to toxinreleased by the fukes leads to cholangitis dilatation of the bile duct, marked ductal epithelial hyperplasia, and fl- brosis leading to cholangiocarcinoma (ble duct carcinoma). ‘© They inhibit tumor suppressor genes (p53) and release of eytokines such as IL-6 and TNF-a (factors associated with carcinogenesis) Inaddition, O. rwerrini can also cause hepatocellular ‘carcinoma; reported mainly from the Northeastern ‘Thailand, Laboratory Diagnosis + St00! microscopy: Demonstration ofthe characteristic Mask-shaped eggs (measures 28-35 jm x 12-19 ym) in the stool establishes the diagnosis. Eggs of Clonorchis: and Opisthorchis are morphologically indistinguishable (Fig. 49.78). ‘= Microscopy ofthe duodenal aspirate is more sensitive than stool microscopy. Entero-testcan be done to take ‘duodenal contents (similar to that is done for Giardia) ‘= Formalin ether concentration should be done when propeptide of cathepsin L proteinase is available for detection of specific IgG4 antibodies against C. sinensis. It is used to evaluate the level of infection and for ‘monitoring the treatment response ‘© Antigen detection: ELISA is also available for the detection of circulating antigen in the serum. Detection fof antigen is more useful sit indicates current infection, ‘& Amuliplex PCR has been developedto detect Clonorchis land Opisthorchis simultaneously. Itis rapid with high sensitivity and specificity Crncarmenr ver ake infections © Tclabendszoe (10 mg/kg once) I the drug of choice for ftasolas 1 Praziquante! (25 mk, tvee doses in 1 day) isthe drug of choice for donorchass and opisthorchiass. Prevention (Liver Fluke) ‘Common preventive measures include sanitary disposal of sewage, and control of snail hosts Fascioliasis can be prevented by avoidance of consumption of alfalfa juice, raw water plants and cleaning them before use ‘& Clonorchiasis and opisthorchiasis can be prevented by avoidance ofeatingraw or undercooked fresh water fish. Hepatosplenic Schistosomiasis Lodging of Schistosoma mansoni and S. japonicum eggs inthe liver can lead to granuloma formation and fibrosis (called as Symmers pipestem fibrosis). ‘ Fibrosis impedes the portal blood flow leading to portal hypertension, hepatomegaly, splenomegaly (enlarged and hard) and gastric varices ‘© S mansoni is increasingly associated with hepatitis € virus; particularly in Egypt and accelerates the ‘occurrence of chronic hepatitis and cirthosis in these patients ‘¢ Hepatitis B virus infection has been associated with S. Japonicum. TOXOCARIASIS ‘Torocariasis is caused by a less common zoonotic nematodes, Toxocara species that rarely infect humans ‘mainly affecting the liver ‘ Twolmportant species are canis (dogroundworm) and T-eati(catroundworm)Puerperal Sepsis Being colonizer of female vagina, streptococci are often. associated with infectious complications of childbirth, ‘usually endometritis and associated bacteremia. Group B streptococci and anaerobic streptococci are more common to cause puerperal sepsis than GAS. ‘Non-suppurative Complications Streptococeal antigens show molecular mimicry with human antigens (Table 52.3), Due to antigenic cross reactivity, antibodies produced against previous streptococcal infections cross react with the human tissue to produce lesions. This accounts for a number of non- ‘suppurative complications such as: Contacts, such as schools and malitary Darracks, oc. infections LABORATORY DIAGNO! S.py09 @ Specimen collection and transport: Depends on the site of the infection 1a Direct smear microscopy: Pus cells with gram-positive cocct in short chains 2 Culture: > Bloodagar: Pinpoint colony with a wide zone of hemolysis > Selective media: Crystal violet blood agar 12 Culture smear: Gram-positive cocc in short chains 2 Identification: > Biochemical dentifation:Itis catalase negative bacitracin sensitive, CAMP test negative » ‘Ruatomated methods such as MALDI-TOF and VITEK Conta. SECTION? @ Skin, Soft Tissue and Musculoskeletal System Infections ome (ATT s. provenesinfections 2 Typing: > ancefeld grouping: Shows group A Streptococeut > Typing of group A Streptococcus: Geifth and erm typing 4 Serology: ASO antibodies and ant-DNase 8 anibodie: Antimicrobial susceptibility testing. However, direct microscopy is not useful when S. pyogenes isa part of normal flora in the sample (e.g, throat swab), Culture ‘The specimens are inoculated onto various media and incubated overnight at 37°C aerobically in presence of 5-10% CO,. S. pyogenes is fastidious, does not grow on Seas o Ripetencee igi nl atest gon of RT ‘Speen otra aoa pe one Sechaba sie ‘Socrates Sod tor nna en Cotiecrer meen epee eae Ea Seen Spaeeiaoacoe Pere er reney + aaa ot ——— ‘Eee + aman en rm et or OE eens (inthe omen cay Suirepemtonsy ‘esau ee ete ae ‘tsa ane eons he och 2 SeanceSECTIONS # Respiratory Tat fectons Jeo wi features of high sweats falgue. and wcea- Sonal fot smeing sputum (in case of pt ang Shacea In primary lng scenes, ladon the ft ne 2 Inseanry lang sen anit cnerage told be Pathogen aected, aed on clr escent eat eg cone enue wens Hngandtheches wal Ther ae vats cases pea «fistnntecon magna her archos and Pulmonary nba Se Our dscsion wil ented {Dntecton slated pcural evn: which may aceur 1 Parapneumoni pleasant ocr soda to ‘acteral pneumonia ore common Iungabue o ‘rons When plural enon eco only Trratens prensa ecole bie ensiingofches pain sun production and dll tee obecred on peresaon 1 Presence afecess pleura dean be demonstted stthrniogaphcor Tecan ee dseparatesthe Ing fom the ches wal by 10 mm, therapeutic ‘horeceael (inage of lal enon) sould beperorned ++ anercaons plore ably cesta ria ‘bern rtm nthe para space 2 avents preset ith fever Wee los, spe ‘nr let best pa ‘Blea TH markers the pleural Od such + Vialpteraetioe stl ein cena ovat {Rtectns uve common, unly goo wnlognved thes efsions esate spontaneous wih n ong termes Laboratory Diagnosis of LTT ‘Specimen Colection Inportne spciens for LAT incude put, Induced sputum, aches! spate, onchoalvelarevage (BAL), protected specimen brush (PSB). ang aspat cece Sata pan nd pe cy ‘Microscopy + Gramsainlngof tie pain oroterspecnensiedane foro purposes 1 Spun ual ps es ae 25 and epi ells ar 10 per low power Ge such sample are ‘eyed ae god qual sputum, where the chance Dtecovery ofthe pater more 2. Presumptive identification: Gram sain gives a plier cle about the etlgial age based Diheimalogy or example 1" Gram-postive ccc pat lanceaate shaped — sugesive of pneumncocas «+ Pleamorphit,gramenepative coceabecil— siggenive of armapiin fra * Aeldfastatningot sputum yet Neca techie ‘Sperormedt demonsatethe a axa eM (aber + GMS stat (Gomer metheramine ser sta) used culture Specimens shouldbe cllected before anublote tery Forbert af organises Sputum culture «standard ealtare method for emia On the pol quay spt specie [rrevealaby Gram ain should besubjeedes cle 1 Specimen re inoculated onto bled ag choc late grand MacComey apa nd inebted over + Beste nn ng + Bod ealtre may aso be performed in addon ‘special i osptazed pao though lds low (5-1 of CAP) suspected, lung aspirate i Subjected for anoeobie ‘tte Sputum notable specnen or anaerobe tre. However for secondary ang abscess sputum Sd tod cues canbe petormed + For M aberelonis Specoens shouldbe inacated ‘to 1} med or automated MTT (yeobactena igo nator ae) elie «Fare pathogen aa ence ‘Serology Antibody Detection) “Antibody detection test can be wed for dagnosis of yical pneumonia pathogens such ax Mycoplasma, (CHlomsc, Csaba ies ‘A ould ee in specific HM aod ter between Sater ead comelscentphos tou samples is eneraly considered dgnontes + Theyre less popular recent days cau ofthe tine ‘se mprial Pharyngitis Dearie Diphtheria solation of the Corynebacterium diphtheriae J Specimen: Throat swab and a portion of pseudomembrane 1 Direct smear > Gram stain: Club shaped gram-positive bacilli with Chinese letter arrangement > Albert's stain:Green bacilli with bluish black metachromatic granules 1 Culture media > Enriched medium: Blood agar, chocolate agar and Loeffler's serum slope » Selective medium: Potassium tellurite agar and Tinsdale medium, produces black colonies 1 Identification > Biochemical tests such as sugar fermentation tests using Hiss's serum sugar media > Automated identification systems such as MALDI-TOF or VITEK diphtheria toxin demonstration 1 In vivo tests (Guinea pig inoculation): Subcutaneous and intracutaneous tests 1 Invitro tests: > Elek’s gel precipitation test » Detection of tox gene-by PCR » Detection of toxin-by ELISA or ICT > Cytotoxicity on cell lines. ahoratory DiaanacicPIP DIAGNOSIS Pneumococcal infections Specimen collection: Sputum, CSF, pleural fluid Direct smear microscopy: Reveals pus cells and lanceolate- shaped gram-positive diplococci, surrounded by a clear halo (due to capsule) ‘Capsular antigen detection in CSF: By latex agglutination ‘C-antigen detection in urine and CSF by ICT ‘Culture » Blood agar: It forms draughtsman or carrom coin shaped colonies » Chocolate agar: It produces greenish discoloration (bleaching effect) Culture smear: Reveals lanceolate-shaped gram-positive diplococci Identification: > Biochemical identification: It is bile soluble, optochin sensitive, inulin fermenter » Automation methods such as MALDI-TOF and VITEK Serotyping: By Quellung reaction or latex agglutination test Molecular methods: Such as multiplex PCR Non-specific findings: 7 acute phase reactant proteins, e.g. C-reactive protein, procalcitonin Antimicrobial susceptibility testing. ln neetaes Plann aecle nf Pn esascnernalt infactiane= Cnn ae Cried |. influenzae infe: a a Specimens: Sputum, blood, CSF > Processed immediately, should never be refrigerated Direct examination: * Pleomorphic gram-negative coccobacilli » Capsule detection: By Quellung reaction > Antigen detection: By latex agglutination test, direct-IF or ELISA Culture: » Blood agar with S. aureus streak line shows satellitism » Others: Chocolate agar, Fildes agar and Levinthal’s agar Identification: » Biochemical tests such as disk test for X and V factor » Automated systems such as MALDI-TOF or VITEK Typing methods such as biotyping and serotyping (using specific antisera) Molecular method: Multiplex PCR (BioFire FilmArray), detecting common agents of pyogenic meningitis in CSF Antimicrobial susceptibility testing‘sete pc a>LABORATORY DIAGNOSIS Pertussis a Q Q og o Specimen: Nasopharyngeal secretions, collected by alginate swabs Direct smear: Gram-negative coccobacilli and pus cells Culture: ® Regan-Lowe medium and Bordet-Gengou agar » Produces mercury drops or bisected pearls colony Culture smear: Reveals small, ovoid gram-negative coccobacilli arranged in'thumb print’ appearance Identification: By automated methods such as MALDI-TOF or VITEK Detection of serum antibodies: By enzyme immunoassays PCR: Detecting [S481 and PT promoter region genes Typing of 8. pertussis: By serotyping and genotyping. >o Non-fermenting Gram-negative Bacilli Cie at Gmina Pree Pseudomonas infections lal ler © Sample collection: Pus, wound swab, urine, etc. nt, 4 Direct smear: Gram-negative bacilli, and pus cells ch 4 Culture: ial > Nutrient agar: Opaque, irregular colonies with metallic sheen (iridescence) and blue green diffusible pigments » Blood agar: f-hemolytic grey moist colonies » MacConkey agar; NLF colonies Selective media: e.g. cetrimide agar G Culture smear and motility: Motile, gram-negative bacilli in Q Identification: he * Catalase positive and oxidase positive ICUT tests: Indole (-), Citrate (+), Urease (-), TSLK/K, gas (-), H,S(-) * Automated identification such as MALDI-TOF or VITEK se 4 Antimicrobial susceptibility testing —== to eran a [ae ener peso n meer 2 ‘thay deacon by hemetenton non te Laboratory Diagnosis SpeamenCoiecton Mak mae asp eo ae nen trot wa + Suna witha synthe ip (og poet or Dacron fab) ae te for specimen calleton (Fg 3) Conon origina seabe we wentcory «+ Tranapars Seb aired pt ide the vat tranapore medi ep at 4 uring tanapore up 04 Ay teeter at-70-C eoationof Vis Bhayourned gg (eink cy) end peary obey ‘dey eal ines have been the methods of choice for froth in cell in was detected by hemadsorpion ot emagginaton tet Beenie of technical diel, Solaion isnot routinely performed for diagnostics pose Direct mmunoftuorercence Test Vial antigens coated ont pitt als can be ess Aetcted tn nal spate By using Drescent age Molecular Methods SUREPCR (reverse trasciptase pomerase cain Feactlon iis highly senate, specie and rapid ae ‘Give cipemet enepontheartacnatype A AN am Ae yp B Negative ate so " WeheraAimenond tt rirerrea a oo nozomi SS sins inn =n = a Merimmioomar 5 se (ornare of ay Ran alo detect pee ‘ypeand sabre ofintensa vis 1 Reame REPER: iis curently the god standard ‘method or suena diagnosis quant has higher sensi and spel) thas RT-PCR wih ‘hehe common sens ena ATHTN AEN ‘ype B) The est expressed ta enn of Moorecence during he ees as deere Fe Satna aie {© Blotire FllmArray Respiratory infuewsntnfers dares a ‘Annibody Detection (erlogy) ‘evious assays ae wulabe to detct subtype specie ‘rum antbie by sing pei enue tgs 683/874 SECTIONS Respater Traces is may wat for sero-epidemloy purpose nat or ‘inka dagoni ts nodies my be ese normal ‘and peeviously used HAI (hemagglutination inhibition) test + Compostiony The ineages of A/HINL, ASN? and IetotnenB sans lchsted in vaccine change every Peeereteinie eee: va a not develop fever or cough as frequently as adults. Clinical Severity Based on the clinical severity the disease may be classified Into the three clinical stages (Table 67.2). covo19 1 Specimens: Throat and nasal swabs 12 NAAT: Nucleic acid amplifiation testing > Format: Realtime RT-PCR, automated formats (CBNAAT and Truenat > Genetargets: Screening (E N,M genes), confirmatory (Rap, NZ genes, etc) 1 Antigen detection assay: Point-of-care test; detects nucleocapsid protein antigen in nasopharyngeal swab 12 Antibody (IgG) detection assay: Used for serosuvellance ‘and survey in high-k and vulnerable group, not for clinical diagnosis Conta. Sequencing: To determine mutations inthe val genome 2 Wiral culture: Used for research purpose Nonspecific tests include: > Radiology (chest CT scan} Ground-glss appearance > Blomarkers 6, D-dimer LABORATORY DIAGNOSIS Laboratory diagnosis is necessary only in specific {indications as per Government of India, such as: + Patient with influenza-like illness (IL) symptoms or severe acute respiratory infection (SARI) % Asymptomatic direct and high-risk contacts of a ‘confirmed case tobe tested ance between day 5 and day 19 of contact + History of international travel in the last 14 daysrenchy- ension- chnoid 2s poor tarts as ollowed tue a ETE Ey sticercosis @ Radiodiagnosis—CT scan and MRI (useful for detecting number, location, size of the cysticerci and the stage of the disease) Q Antibody detection in serum or CSF— » ELISA (using crude extract of cysticerci) » Western blot (using 13 kDa LLGP Ag) Antigen detection in serum or CSF—ELISA Lymphocyte transformation test Histopathology of muscles, eyes, subcutaneous tissues or brain biopsies—can detect cysticerci FINAC of the cyst and then staining with Giemsa Fundoscopy of eye—detects larvae Modified Del Brutto diagnostic criteria. ooo oocContd... LABORATORY DIAGNOSIS Syphilis » TRUST (toluidine red unheated serum test) » USR (Unheated serum reagin test). Specific/Treponemal test: Specific antibodies are detected by using T. pallidum antigens » TP (Treponema pallidum immobilization test) >» FTA-ABS (Fluorescent treponemal antibody absorption test) TPA (T. pallidum agglutination test) TPHA (T. pallidum hemagglutination test) TPPA (T. pallidum particle agglutination test). Polymerase chain reaction (PCR) vw ¥