Catholic University

Name: Yainel Romero Calle Level: IV Profesor MA John Moscoso

Norovirus Gastroenteritis in Immunocompromised Patients

Infectious gastroenteritis is a common, acute illness that is characteristically self-limiting, but it can become
debilitating and life-threatening in immunocompromised patients. Noroviruses are major pathogens among
the microbes associated with gastroenteritis in both immunocompetent and immunocompromised hosts.

In the United States, noroviruses are the single most common cause of acute gastroenteritis in adults that
results in a visit to the hospital emergency department, and they are second only to rotaviruses as a major
cause of severe diarrhea in infants and young children. In developing countries, noroviruses are estimated to
cause more than 200,000 deaths annually among children younger than 5 years of age, and it is predicted that
these viruses will become the predominant cause of diarrhea in all age groups worldwide once rotavirus
infection is controlled through vaccination.

Noroviruses are increasingly recognized as an important cause of chronic gastroenteritis in

immunocompromised patients, as reflected by the growing number of clinical case reports.

A comparison of the known features of norovirus gastroenteritis in immunocompetent versus

immunocompromised hosts highlights the potentially serious outcome of this illness in persons who cannot
adequately clear the virus.

The purpose of this review is to summarize recent developments in norovirus research that are relevant to
the prevention and management of norovirus gastroenteritis in immunocompromised patients.

Norovirus Classification and Structure

Noroviruses are small, nonenveloped viruses with a single-stranded RNA genome that make up the genus
norovirus of the family Caliciviridae. They are divided into six major genogroups designated GI through
GVI. GI and GII contain the majority of norovirus strains associated with human disease and are further
divided into about 30 genotypes. A single genotype, GII.4, has been associated with the majority of global
outbreaks since the mid-1990s, when active surveillance with molecular diagnostic techniques was initiated.

I.Read the paragragh above and write TRUE or FALSE. IF IT IS FALSE EXPLAIN WHY?

1.Infectious gastroenteritis is a common, acute illness that is characteristically self-limiting T

2.Noroviruses are major pathogens among the microbes associated with gastroenteritis T

3.In the United States, noroviruses are the single most common cause of acute tenditis F

In the United States, noroviruses are the single most common cause of acute gastroenteritis.

4.They are fifth only to rotaviruses as a cause of severe diarrhea in infants & children F

Because they are second only to rotaviruses as a major cause of severe diarrhea in infants and young children

5.In developing countries, noroviruses are estimated to cause more than 2,000 deaths T
6.It is predicted that these viruses will become the predominant cause of apnea in groups F

Because these viruses will become the predominant cause of diarrhea in all age groups worldwide once rotavirus
infection is controlled through vaccination.

7.Noroviruses are decreasingly recognized as a cause of chronic gastroenteritis in blind patients F

Because Noroviruses are increasingly recognized as an important cause of chronic gastroenteritis in

immunocompromised patients.

8.The purpose of this review is to summarize recent developments in norovirus research T

9.Noroviruses are big, well developed viruses with a double-stranded DNA genome F

Because, Noroviruses are small, nonenveloped viruses with a single-stranded RNA genome

10.They are divided into two major genogroups designated GI through GVI. GI and GII F

Because they are divided into six major genogroups designated GI through GVI. GI and GII

II.CHOOSE THE BEST ANSWER AND COLOR WITH YELLOW

1.How many teeth does an adult human have?

32
24
30
16
2.What kind of tooth is adapted for cutting?

Canine
Incisor
Premolar
Molar
3.Which of these pioneered the field?

William Ferguson
Maurice Stone
Edward Angle
Joe Rogers
4.What is misalignment between dental arches called?

Malocclusion
Plaque
Floss
Dental occlusion
5.Which of these is not located in the oral cavity?

Tongue
Gum
Tonsils
Pharynx
6.How many are the main parts of a bracket?
4

7
7.Which of these parts of brackets is used to spot weld onto orthodontic bands?

Wire slots
Bracket base
Tie wing
Arch wires
8.Which of these is used on the premolar?

Orthodontic bands
Arch wire
Coils
Springs
9.Which of these is done to prevent orthodontic movement?

Malocclusion
Adjunctive therapy
Alveolar decortication
Disocclusion
10.Which of these is not a way of treating malocclusion?

Growth Modification
Orthodontic Camouflage
Facial Aesthetics
Orthognathic Surgical Treatment

11.Why could it be dangerous to eat raw cookie dough?

o A. It Expands In Your Stomach

o B. It's Corrosive
o C. It Has Too Much Sugar
o D. It May Contain Raw Eggs

12.Which is helpful for healthier teeth?

o A. Using A Fluoride Toothpaste

o B. Eating Sweets Between Meals
o C. Brushing Only Every Other Day
o D. Not Flossing Your Teeth

13.What company made a weight-losing guy name Jared their spokesperson?

o A. LA Fitness
o B. Subway
o C. Diet Coke
o D. Trim Spa

14.Citrus fruits are a great source of which vitamin?

o A. Vitamin D
o B. Vitamin F
o C. Vitamin C
o D. Vitamin B12

15.A calorie is a unit of measurement used to measure what?

 o A. Amount Of Water In Food
o B. Amount Of Energy In Food
o C. Amount Of Fat In Food
o D. Amount Of Protein In Food

16.What is the body's main source of energy?

o A. Water
o B. Minerals
o C. Carbohydrates
o D. Vitamins

17.Vitamin A is important for what?

o A. Smell
o B. Hearing
o C. Hair Growth
o D. Vision

18.Which of the following are needed to build, repair and maintain body tissue?

o A. Fats
o B. Vitamins
o C. Proteins
o D. Minerals

19.What is Glucose?

o A. A Mineral
o B. A Sugar
o C. A Carbohydrate
o D. A Protein

20.Which dietary supplement was banned by the FDA in February 2004?

o A. Chitosan
o B. Chromium
o C. Ephedrine
o D. Pyruvate

21.What does fiber help to prevent?

o A. Digestion
o B. Muscle Weakness
o C. Constipation
o D. High Blood Pressure

22.What is the most common contaminant found in fish?

 o A. Dioxins
o B. Mercury
o C. Polychlorinated Biphenyls
o D. Parasites

23.Which fruit is high in potassium?

o A. Apple
o B. Banana
o C. Kiwi
o D. Peach

24.Which vitamin may help to shorten the duration of colds?

o A. B6
o B. D
o C. C
o D. B12

25.What do antioxidants neutralize?

o A. LDL Cholesterol
o B. HDL Cholesterol
o C. Stomach Acid
o D. Free Radicals

26.

What's the other name for physiotherapy?

o A. Fitness
o B. Physics
o C. Physical therapy
o D. Aerobics

27.
 What's the other name for manual therapy?

o A. Manipulative therapy
o B. Therapy
o C. Massage
o D. Thai massage

28.

What's electrotherapy?

o A. It is the use of electrical energy as a medical treatment.

o B. It is the use of water pulses.
o C. It is the use of heat for healing.
o D. It is the use of massage for healing.

29.

What's the human musculoskeletal system?

o A. It is an organ system that gives humans the ability to move using their
muscular and skeletal systems.
o B. It is a system that gives humans the ability to move using their muscular and
skeletal systems
o C. It is an organ system that gives humans the ability to move using their
skeletal systems
o D. It is a system that gives humans the ability to move using their muscular
systems

30.
 What's neurology?

o A. It is a branch of medicine dealing with heart diseases.

o B. It is a branch of medicine dealing with disorders of the nervous system.
o C. It is a branch of medicine dealing with brain problems.
o D. It is a branch of medicine dealing with pulmonary diseases.

31.

What's EMG?

o A. Emergency unit
o B. Electromagnetism
o C. Electromyography
o D. Emergency services

32.

What's the other term for rehabilitation hospitals?

o A. Inpatient rehabilitation hospitals.

o B. Patient rehab center
o C. Inpatient centers
o D. Rehabilitation centers
33.

What kind of patients are brought at hospices?

o A. New patients.
o B. Patients who have been in a coma for a while.
o C. The mentally challenged ones.
o D. The chronically ill, terminally ill, and the seriously ill.

34.

Who was Hippocrates of Kos?

o A. He was a French Doctor.

o B. He was a German Scientist of the 18th Century.
o C. He was a Greek physician of the age of Pericles.
o D. He invented massaging oils.

35.

What's hydrotherapy?

o A. It is a part of alternative medicine that involves the use of water for pain relief
and treatment.
o B. It involves the use of force for pain relief and treatment.
o C. It involves the use of pressure for pain relief and treatment.
o D. It is a part of alternative medicine that involves the use of energy for pain
relief and treatment.
III.Write the right definition
Diabetes mellitus Heart rate Angina pectoris Diaphoresis S-T segment
Anemia Electrocardiography Myocardial infarction Pneumonia Asthma

Asthma is a chronic (long-lasting) inflammatory disease of the airways. In those susceptible to asthma, this
inflammation causes the airways to spasm and swell periodically so that the airways narrow. The individual then must
wheeze or gasp for air.
Pneumonia An acute or chronic disease marked by inflammation of the lungs, especially an infectious disease caused
by viruses, bacteria, or other pathogens, such as mycoplasmas. Individuals with pneumonia often have abnormal chest
x-rays that show areas with fluid in the infected part of the lungs.
Myocardial infarction commonly known as a heart attack, results from the interruption of blood supply to a part of
the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary arteryfollowing
the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (cholesterol and fatty acids)
and white blood cells (especially macrophages) in the wall of an artery.
Electrocardiography is a transthoracic (across the thorax or chest) interpretation of the electrical activity of
the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a
device external to the body.
Anemia is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood.
S-T segment the part of an electrocardiogram immediately following the QRS complex and merging into the T wave.
Diaphoresis is excessive sweating commonly associated with shock and other medical emergency conditions.
Angina pectoris is chest pain due to ischemia of the heart muscle, generally due to obstruction or spasm of
the coronary arteries.[1] The main cause of Angina pectoris is Coronary Artery Disease, due to atherosclerosis of the
arteries feeding the heart.
Heart rate is the number of heartbeats per unit of time, typically expressed as beats per minute (bpm). Heart rate can
vary as the body's need to absorb oxygen and excrete carbon dioxide changes, such as during physical exercise, sleep
or illness.
Diabetes mellitus is a group of metabolic diseases in which a person has high blood sugar, either because
the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced

IV. Identify the different part of Nervous System

Common peroneal nerve Spinal cord Intercostal nerve Sacral plexus Ulnar nerve
Digital nerve Superficial peroneal nerve Lumbar plexus Brachial plexus Sciatic nerve
Cerebrum Cerebellum Radial nerve Median nerve
 1. Cerebrum
2. Cerebellum
3. Spinal cord
4. Brachial plexus
5. Intercostal nerve
6. Radial nerve
7. Median nerve
8. Ulnar nerve
9. Lumbar plexus
10. Sacral plexus
11. Digital nerve
12. Sciatic nerve
13. Superficial peroneal
nerve
14. Common peroneal nerve

The norovirus genome encodes seven nonstructural and two structural proteins Genomic Organization and
Atomic Structure of the Norovirus Capsid.). The majority of reverse-transcriptase–polymerase-chain-
reaction (RT-PCR) diagnostic assays target the RNA polymerase region of the genome because of its higher
sequence conservation among strains. VP1 is the major structural protein of the virus that self-assembles into
viruslike particles (VLPs), which are being evaluated as possible vaccines; VP2 is a minor structural protein.
Noroviruses bind saccharides of the human histo–blood group antigens (HBGAs) within their VP1 protruding
2 (P2) domain, a proposed mechanism for facilitating viral entry into the epithelial cells of the gastrointestinal
tract. It is thought that susceptibility to norovirus in humans is determined by allelic variation of HBGAs,
with each norovirus strain presenting a characteristic HBGA-binding profile. Thus, a certain genetic
background might confer resistance to the infection, as in the case of persons classified as nonsecretors (i.e.,
persons in whom these carbohydrates are not expressed on the surface of intestinal epithelial cells), who are
resistant to infection with Norwalk virus, a GI.1 strain.

Noroviruses in Immunocompromised Patients

Prolonged norovirus and illness have been reported in persons who are immunosuppressed as a result of
congenital immunodeficiency, immunosuppressive therapy for the purpose of maintaining an organ allograft,
cancer chemotherapy, and infection with the human immunodeficiency virus (HIV). Immunocompromised
patients can be exposed to noroviruses from many sources, including family members, health care workers,
contaminated food or water, and the environment (including nosocomial sources). The overall incidence of
norovirus gastroenteritis in hospital and community settings has not yet been determined. An increasing
number of studies show that immunosuppressive therapy is a risk factor for norovirus infection. According
to one report, 18% of patients who underwent allogeneic hematopoietic stem-cell transplantation (HSCT)
contracted norovirus over a 1-year period, many after they had received intensified immunosuppressive
regimens for suspected graft-versus-host disease (GVHD). A 2-year survey of renal-transplant recipients
showed that 17% of the patients were chronically infected with norovirus and had intermittent diarrhea.

Noroviruses are highly resistant to harsh environmental conditions, and the infectious oral dose is estimated
to be less than 20 viral particles. In immunocompetent adults, norovirus gastroenteritis is characteristically
acute (24 to 48 hours in duration) and self-limiting, but in immunocompromised adults, the disease can
become chronic and can persist for weeks to years. A marked predominance of wintertime norovirus
infections has been widely described in the general population, and common names are winter-vomiting
disease and stomach flu. In contrast, in a case–control study of children with cancer and in a case series of
patients who had undergone HSCT, the rate of illness was reported to be unchanged throughout the year.

It is not yet clear whether noroviruses are transmissible to immunocompetent adults from patients with
chronic viral shedding, the latter having been proposed as a possible reservoir of novel genetic variants.
Surveillance studies suggest that most nosocomial norovirus infections are acquired in the community;
nosocomial outbreaks in which persons with immunodeficiency disorders are the source are rare. Vomiting
and diarrhea have been linked to high viral loads in patients undergoing immunosuppressive therapy,
whereas asymptomatic shedding was associated with lower viral loads. These findings, as well as those
involving immunocompetent hosts, suggest that in most cases the virus is transmitted from symptomatic
persons, even when high levels of the virus are shed in the stool for prolonged periods after symptoms have
resolved.

Chronic norovirus gastroenteritis can present specific clinical challenges in patients with an impaired
immune response, as compared with immunocompetent hosts. For example, norovirus-induced diarrhea in
immunosuppressed renal-transplant recipients is characterized by dramatic weight loss and lasts
considerably longer than treatable bacteria- or parasite-induced diarrhea (i.e., an average of 9 months vs. 1
month). The malnutrition, dehydration, and altered intestinal mucosal barrier associated with prolonged
norovirus-related diarrhea can increase morbidity and worsen the outcome of the underlying disease.
Noroviruses were reported to be the cause of death in one patient 49 days after the onset of symptoms and in
another patient after 1 year of unresolved gastroenteritis.

Diagnosis of Norovirus Gastroenteritis

It is difficult to diagnose norovirus gastroenteritis on the basis of clinical features alone. Diarrhea is a common
complication in transplant recipients: gastroenteritis develops in 80% of patients who have undergone
allogeneic HSCT, as a result of conditioning therapy, GVHD, drugs, or infectious agents. Symptoms of acute
norovirus disease can include diarrhea, fever, and projectile vomiting, in contrast to the characteristic
combination of diarrhea and nausea (without vomiting) observed in GVHD. Although a provisional diagnosis
might be made, use of a reliable diagnostic assay is crucial to distinguish infectious diarrhea from clinical
complications such as graft rejection and GVHD, since these conditions require diametrically opposed
approaches to management (i.e., decreasing immunosuppression in infectious diarrhea and increasing it in
graft rejection and GVHD).

Noroviruses are shed in stool, and norovirus-specific antigens and RNA can be detected in stool samples.
Regular or quantitative real-time RT-PCR assay is the most widely used laboratory method for diagnosing
norovirus gastroenteritis, but several other assays are now available. Computed tomography has been
reported to aid in discriminating between norovirus infection and GVHD, since norovirus-infected patients
have pronounced bowel-wall edema restricted to the small intestine, which is infrequently seen in patients
with intestinal cytomegalovirus infection or GVHD. Precise and timely diagnosis of norovirus infection by
means of laboratory testing is essential in intestinal-transplant recipients, since the pathological
characteristics of norovirus infection are similar to those seen in allograft rejection, with chronic
inflammatory change, apoptotic cells, and blunted villi. The diagnosis of gastrointestinal GVHD, a well-
described complication of HSCT, also relies on histopathological findings that could be mistaken for those
associated with norovirus infection, in which numerous apoptotic bodies are observed.

Norovirus Diversity and Evolution in Immunocompromised Patients

The diversity of norovirus genotypes circulating in the community, where GII.4 is most prevalent, is reflected
in the genotypes detected in persons with an impaired immune system. There have been no reported strain
differences among the norovirus genotypes with regard to symptoms, severity, or progression to chronicity
in immunocompromised hosts.

Intrahost variation and evolution of the viral genome over extended periods of shedding have been studied in
detail in several patients persistently infected with norovirus. An analysis of the viral variants present in the
stool of infected persons showed that in immunocompetent persons in whom the infection resolved during the
acute phase, a single major variant predominated, whereas immunocompromised patients with chronic
norovirus infection had a diverse viral population.

These data indicate that a chronic infection without immune pressure allows the generation of a diverse
norovirus population in the host; however, at present there is no epidemiologic evidence to suggest that these
variants become prevalent as epidemic strains in the community. Despite the increased viral heterogeneity
generated during a chronic norovirus infection, the amino acid residues that interact with HBGA ligands
remain conserved — a finding that is consistent with the proposed importance of this interaction in the
binding of virus to intestinal epithelial cells.

The shedding of norovirus by immunocompromised patients for an extended period of time has provided a
unique opportunity to monitor the effects of genetic changes that lead to the accumulation of alterations in
the amino acid makeup of the virus. Evolution of the norovirus genome in patients infected for extended
periods is relatively rapid (3.3% amino acid substitutions per year), considering that GII.4 noroviruses have
been shown to have accumulated only a 10% amino acid difference in their viral capsid after circulating in
the community for 31 years. Accurate determination of a substitution rate could be useful in assessing
whether a patient with chronic shedding continues to have the same norovirus strain or has been reinfected
with a new strain; it may also help track norovirus transmission among immunocompromised patients in a
common setting. This “time-clock” approach may prove useful in establishing the role of nosocomial
transmission in immunocompromised patients and in evaluating the efficacy of treatment because knowledge
of the rate at which genetic differences are generated can be used to determine whether a persistent strain is
under investigation or a new strain has been introduced.

Prevention and Treatment of Norovirus Infection in Immunocompromised Patients

No vaccines or specific antiviral agents are currently available to prevent or treat norovirus infection, but
progress has recently been made in vaccine development. Norovirus vaccines have been tested in both humans
and chimpanzees, and the results of these studies were used to determine correlates of protection and duration
of immune response. It has also been reported that both T-cell and B-cell responses are necessary to clear
norovirus. In a mouse model, CD4+ and CD8+ cells were required for clearance of murine norovirus in the
intestine. Norovirus clearance in patients with chronic infection has been shown to be associated with the
recovery of T cells; in one study, symptoms improved in patients with HIV infection who had an increased
CD4+ count.

Currently, the treatment of patients with norovirus gastroenteritis is primarily supportive and focuses on
prevention and reversal of dehydration. Chronic norovirus infections in transplant recipients may also
require the adjustment of immunosuppressive therapy during prolonged illness. Passive antibody therapies
have been tested in individual case studies, and evidence of their efficacy in treating patients with norovirus
gastroenteritis is mostly anecdotal. Oral administration of breast milk or immune globulin has yielded mixed
results, probably reflecting differences in the quality and quantity of norovirus-specific antibodies in the
treatment administered. Both immune globulin and breast milk have been administered successfully through
a duodenal tube (in an attempt to bypass the adverse acidic environment of the stomach) to treat prolonged
norovirus infection in a heart-transplant recipient, but this approach failed to clear norovirus in a patient
with a gammaglobulinemia.

Certain commonly used antiviral drugs such as ribavirin have failed to clear norovirus in chronically infected
patients. Nitazoxanide (an antiprotozoal drug) was reported to significantly reduce the time to resolution of
symptoms related to both rotavirus- and norovirus-induced diarrhea in immunocompetent patients, and
symptoms of severe norovirus gastroenteritis were described as markedly reduced after 1 day of treatment
in a patient who underwent HSCT. However, quantification of the exact genomic load in this patient was not
reported, and viral shedding persisted for a month after treatment. Further testing will be needed to
determine the efficacy of this drug in immunocompromised patients.

Finally, it has been suggested that the class of immunosuppressive drugs provided might affect the clearance
of norovirus, since certain drugs also have antiviral properties. A significant increase in the antiviral
properties of the immunosuppressive therapy administered (as measured by the incidence of cytomegalovirus
infections in immunodeficient patients) was observed only when a switch was made from an antimetabolite
(azathioprine or mycophenolate) to a mammalian target of rapamycin (mTOR) inhibitor (sirolimus or
everolimus). The incidence of norovirus gastroenteritis in patients being treated with different types of
immunosuppressive agents will require more study.

Conclusions

Given the substantial toll that noroviruses can take on the prognosis for and quality of life of patients with a
deficient immune response, appropriate measures should be taken to reduce the risk of norovirus infection.
First and foremost, rigorous personal hygiene, especially hand-washing, is the single most effective measure
to combat norovirus transmission. This measure is crucial, given the fact that 80% of hospital surfaces were
found to be contaminated with 21 different noroviruses during environmental surveillance in a unit for
children with immunodeficiency disorders. Immunocompromised patients should avoid contact with persons
who are acutely ill with gastroenteritis and should follow guidelines designed to prevent infections with enteric
pathogens. Such patients should consume foods considered to be safe according to the principles designed to
minimize the risk of foodborne diseases. Although it is prudent to isolate patients who have chronic norovirus
infection, the virulence of noroviruses shed in the stool in such patients has been called into question, given
the absence of reported secondary cases. Finally, norovirus testing can now be included in the care of
immunocompromised patients with acute or chronic gastroenteritis of unknown cause. Widespread use of
diagnostic assays and continued research will help clarify the precise disease burden and epidemiologic
features of norovirus infection in this population and will improve the clinical care of those infected.

V.Read the paragragh above and answer the questions

1.What does the norovirus genome encode? The norovirus genome encodes seven nonstructural and two structural
proteins Genomic Organization and Atomic Structure of the Norovirus Capsid.).

2.What is VP1’s function? VP1 is the major structural protein of the virus that self-assembles into viruslike particles
(VLPs)

3.What do Noroviruses bind? Noroviruses bind saccharides of the human histo–blood group antigens (HBGAs)
within their VP1 protruding 2 (P2) domain, a proposed mechanism for facilitating viral entry into the epithelial cells
of the gastrointestinal tract.

4.How is susceptibility to norovirus in humans determined? Why? Because. It is thought that susceptibility to
norovirus in humans is determined by allelic variation of HBGAs, with each norovirus strain presenting a
characteristic HBGA-binding profile.
5.What might certain genetic background confer? A certain genetic background might confer resistance to the
infection, as in the case of persons classified as nonsecretors

6.Where can Immunocompromised patients be exposed to noroviruses? Why? Because, Immunocompromised

patients can be exposed to noroviruses from many sources, including family members, health care workers,
contaminated food or water, and the environment (including nosocomial sources).

7.What does an increasing number of studies show? An increasing number of studies show that
immunosuppressive therapy is a risk factor for norovirus infection

8.What percentage of patients who underwent allogeneic hematopoietic stem-cell transplantation (HSCT)
contracted norovirus over a 1-year period? Why? Because, According to one report, 18% of patients who
underwent allogeneic hematopoietic stem-cell transplantation (HSCT) contracted norovirus over a 1-year period,
many after they had received intensified immunosuppressive regimens for suspected graft-versus-host disease
(GVHD).

9.What did a 2-year survey of renal-transplant recipients show? Showed that 17% of the patients were
chronically infected with norovirus and had intermittent diarrhea.

10.How long is norovirus gastroenteritis characteristically acute? Why? In immunocompetent adults, norovirus
gastroenteritis is characteristically acute (24 to 48 hours in duration) and self-limiting, but in immunocompromised
adults, because the disease can become chronic and can persist for weeks to years.

11.Is it clear whether noroviruses are transmissible to immunocompetent adults from patients with chronic
viral shedding? Why? Why not? Yes, because It is not yet clear whether noroviruses are transmissible to
immunocompetent adults from patients with chronic viral shedding, the latter having been proposed as a possible
reservoir of novel genetic variants. Surveillance studies suggest that most nosocomial norovirus infections are
acquired in the community; nosocomial outbreaks in which persons with immunodeficiency disorders are the source
are rare.

12.Why are vomiting and diarrhea have been linked to high viral loads in patients undergoing
immunosuppressive therapy? Because, Vomiting and diarrhea have been linked to high viral loads in patients
undergoing immunosuppressive therapy, whereas asymptomatic shedding was associated with lower viral loads.

13.Why can chronic norovirus gastroenteritis present specific clinical challenges in patients with an impaired
immune response? Because, Chronic norovirus gastroenteritis can present specific clinical challenges in patients
with an impaired immune response, as compared with immunocompetent hosts.

14.What percentage gastroenteritis develop in patients who have undergone allogeneic HSCT? Why?
Gastroenteritis develops in 80% of patients who have undergone allogeneic HSCT

15.Why has computed tomography been reported to aid in discriminating between norovirus infection and
GVHD? Because. Computed tomography has been reported to aid in discriminating between norovirus infection
and GVHD, since norovirus-infected patients have pronounced bowel-wall edema restricted to the small intestine,
which is infrequently seen in patients with intestinal cytomegalovirus infection or GVHD.

16.What did an analysis of the viral variants present in the stool of infected persons show? Why? Because, an
analysis of the viral variants present in the stool of infected persons showed that in immunocompetent persons in
whom the infection resolved during the acute phase, a single major variant predominated, whereas
immunocompromised patients with chronic norovirus infection had a diverse viral population.

17.How fast is evolution of the norovirus genome in patients infected for extended periods? Why? Because,
the Evolution of the norovirus genome in patients infected for extended periods is relatively rapid (3.3% amino acid
substitutions per year), considering that GII.4 noroviruses have been shown to have accumulated only a 10% amino
acid difference in their viral capsid after circulating in the community for 31 years.
18.What happened with CD4+ and CD8+ cells in a mouse model? In a mouse model, CD4+ and CD8+ cells
were required for clearance of murine norovirus in the intestine. Norovirus clearance in patients with chronic
infection has been shown to be associated with the recovery of T cells; in one study, symptoms improved in patients
with HIV infection who had an increased CD4+ count.

19.Has ribavirin cured totally to clear norovirus in chronically infected patients? Why? Why not? What
happened with Nitazoxanide? Because the Certain commonly used antiviral drugs such as ribavirin have failed to
clear norovirus in chronically infected patients. Nitazoxanide (an antiprotozoal drug) was reported to significantly
reduce the time to resolution of symptoms related to both rotavirus- and norovirus-induced diarrhea in
immunocompetent patients, and symptoms of severe norovirus gastroenteritis were described as markedly reduced
after 1 day of treatment in a patient who underwent HSCT

20.What percentage of hospital surfaces were found to be contaminated? How many different noroviruses
during environmental surveillance in a unit for children with immunodeficiency disorders were present?
Why? Because, 80% of hospital surfaces were found to be contaminated with 21 different noroviruses during
environmental surveillance in a unit for children with immunodeficie ncy disorders. Immunocompromised patients
should avoid contact with persons who are acutely ill with gastroenteritis and should follow guidelines designed to
prevent infections with enteric pathogens.

VI. SELF TEST

MRSA Methicillin-ResistantStaphylococcus aureus

1.MRSA describes a specific type of bacteria that are resistant to certain

antibiotics.
• True • False

2.Is MRSA contagious?

• Yes • No

3.A commonly used word to describe MRSA is...

A Superbug B E. coli C Salmonella D Rash

4.MRSA bacteria are most likely found...

• In the air • In hospitals
5.Some of us carry MRSA bacteria in our...
A Mouths B Noses C Eyes D Throats

6.What is the best defense against MRSA?

A Good hygiene B Avoiding antibiotics C Vaccine D All of the above

7.MRSA most often enters the body through droplets from coughing or sneezing.
• True • False

8.MRSA can cause sepsis, which is an infection of the blood.

• True • False

9.A MRSA skin infection can often mimic a ________________.

A Cut B Scrape C Spider bite D Stye

10.MRSA infections can cause complications such as...

A "Flesh-eating" disease B Pneumonia C Death D All of the above

11.The skin condition cellulitis can be caused by MRSA or by other bacterial

types.
• True • False

Common Skin Conditions

12.Which of these painful viral skin conditions is shingles?

(a) (b)

13.Which image below represents the classic rings of the fungal disease
ringworm?

(a) (b)

14.Which image below is psoriasis, a non-contagious rash of thick plaques and

silvery scales?

(a) (b)

15.Which of these images shows the skin disease known as rosacea?

 (a) (b)

16.Referred to as a skin abscess, which of these is considered a boil?

(a) (b)

17.Scabies bites caused which of these itchy red raised bumps?

(a) (b)

18.Which of these images is a plantar wart caused by the human papillomavirus

(HPV)?

(a) (b)
19.Caused by a fungus, which of these images is athlete's foot?
 (a) (b)

20.Characterized by small flaps that hang off the skin, which image shows skin
tags?

(a) (b)

21.Excessive exposure to sunlight can cause which skin cancer depicted here?

(a) (b)

22.One of these conditions that is transmitted by ticks is Rocky Mountain Spotted

Fever – which is it?

(a) (b)
23.Which of the children below has contracted head lice?

(a) (a)

24.Identify which image below is a result of allergic contact dermatitis?

(a) (b)

25.Which of these women is experiencing the condition known as melasma?

(a) (b)