M IC R O B IO L O G Y /P A T H O L O G Y L E G E N D

T o p ic C a rd s T o p ic C a rd s

v ir u s 1 -2 7 h e a rt d is o rd e r s 1 6 1 -1 6 5

b a c te r ia 2 8 -6 0 in f e c t io n s 1 6 6 -1 7 5

te rm s 6 1 -6 5 le u k e m ia 1 7 6 -1 7 9

s u b s ta n c e s 6 6 -7 5 im m u n o lo g y 1 8 0 -1 9 6

c e lls /o r g a n e lle s 7 6 -8 0 v a c c in e s 1 9 7 -2 0 2

m is c e lla n e o u s 8 1 -8 6 d is e a s e s 2 0 3 -2 1 8

fu n g i 8 7 -9 2 d is o rd e r s 2 1 9 -2 3 9

p a r a s ite s 9 3 -9 6 in fla m m a t io n & n e c r o s is 2 4 0 -2 4 7

k id n e y d is e a s e 9 7 -1 0 2 s y n d ro m e s 2 4 8 -2 5 7

liv e r d is e a s e 1 0 3 -1 0 8 h e m o d y n a m ic d y s fu n c tio n 2 5 8 -2 6 1

lu n g d is o r d e r s 1 0 9 -1 1 6 a n tib io tic s 2 6 2 -2 6 9

n e o p la s m s 1 1 7 -1 4 2 o r a l c a v ity 2 7 0 -2 7 7

b lo o d d is o r d e r s 1 4 3 -1 5 4 in fe c tio n c o n tr o l 2 7 8 -3 1 6

b o n e d is o rd e r s 1 5 5 -1 6 0
v ir u s 1

F ro m th e fo llo w in g lis t s e le c t t h e T H R E E ite m s a s s o c ia te d w ith

H e p a titis C .

• p ic o r n a v ir u s
• ss R N A
• o r a l- a n a l
• fla v iv ir u s
• ds DNA
• h e p a d n a v ir u s
• b lo o d b o r n e
• v a c c in a t io n a v a ila b le

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • ss RNA
• fla v iv ir u s
• b lo o d b o rn e
V iru s F a m ily G en o m e T ra n s m is s io n D is e a s e

H ep atitis A P ico m n v in is ss RN A O ral-anal H ep atitis A

H ep atitis B H epadnavirus dsD N A B lood b o rn e H ep atitis B

H ep atitis C F lavivirus ss RN A B lood b o rn e H epatitis C

H ep atitis D D eltav iru s ss R N A B lo o d borne H epatitis D: C an o n ly infect cells

prev iou sly infected w ith hep atitis B

H ep atitis E C aliciviru s ss RN A O ral-anal H ep atitis E

in fluenza O rth om yxovirus ss RN A R espiratory droplets Influenza

R esp irato ry syncytial P aram yxovirus ss R N A R espiratory d roplets B ronch iolitis an d p n eu m o n ia in in­
virus fants

M easles P aram yxovirus ss R N A R esp irato ry droplets M easles (ru b eo la)

M um ps P aram yxovirus ss R N A R esp irato ry droplets M um ps

R ubella T o g a v in is ss R N A R esp irato ry droplets R u b ella (G erm an m easles)

A denovirus A den o v iru s d s D NA R espiratory droplets P haryngitis, P neum onia,

C o n ju nctivitis

R hin o v iru s P ico m av iru s ss RN A R espiratory dro p lets C om m on co ld

H IV R etro v iru s ss R N A B lood b o rn e. G enital A ID S

C yto m eg alov iru s H erpesvirus ds DNA R espiratory droplets M on o n u cleo sis syndrom e

E p stcin -B arr H erp esv iru s ds DNA R espiratory droplets Infectious m onon u cleo sis

HSV-1 H erpesvirus ds DNA O ral (saliva) G in g iv o sto m atitis. H erp es labialis

H S V -2 H erpesvirus ds DNA G enital (sex u ally G en ital herpes

transm itted disease)
v iru s 2

R o ta v ir u s e s a r e th e m o s t c o m m o n c a u s e o f g a s tr o e n te r itis in c h ild re n
(2 a n d u n d e r ).
R e o v ir u s e s h a v e a n ic o s a h e d r a l c a p s id c o m p o s e d o f a n o u te r a n d
in n e r p ro te in s h e ll c o n ta in in g a d o u b le -s tr a n d e d s e g m e n te d g e n o m e .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• t h e fir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
• t h e fir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s ta t e m e n t s a r e tr u e
R e o v ir u s e s a r e n o n - e n v e lo p e d a n d h a v e a n ic o s a h e d r a l c a p s id c o m p o s e d o f
a n o u t e r a n d in n e r p r o te in s h e ll c o n t a in in g s e g m e n t e d , d o u b le -s tr a n d e d
RNA.
Im p o r ta n t: T h e v ir io n c o n ta in s a n R N A -d e p e n d e n t R N A p o ly m e r a s e , w h ic h
is r e q u ir e d b e c a u s e h u m a n c e lls la c k t h is e n z y m e a n d th e r e f o r e c a n n o t
s y n t h e s iz e m R N A fr o m a n R N A te m p la t e . T h e y r e p lic a te in th e c y to p la s m .
Im p o r ta n t m e m b e r s o f r e o v ir u s fa m ily th a t c a u s e h u m a n d is e a s e :
• R o t a v ir u s e s ( a ls o c a lle d g a s t r o e n t e r it is v ir u s t y p e B ): t h e m o s t c o m m o n
c a u s e o f g a s tr o e n te r itis in c h ild r e n ( 2 a n d u n d e r ) . It is s p r e a d v ia th e
fe c a l o r a l r o u t e . It c a n s u r v iv e th e a c id ic c o n d it io n s in th e s to m a c h , a ft e r
w h ic h it is a d s o r b e d in th e s m a ll in te s tin e . A d u lt s m a y b e c o m e in fe c te d
w it h r o t a v ir u s b u t s y m p t o m s a r e u s u a lly m ild o r a b s e n t.
• C o ltiv ir u s ( a ls o c a lle d C o lo r a d o t ic k f e v e r v ir u s ) : c a u s e s C o lo r a d o tic k
fe v e r .
V ir a l g a s t r o e n t e r it is is a s e lf - lim it in g d is e a s e , o ft e n r e fe r r e d t o a s th e 2 4 - h o u r
o r in te s tin a l flu . A n in f lu e n z a v ir u s d o e s n o t c a u s e it. It is a s s o c ia t e d w it h R N A
v ir u s e s a n d is o ft e n d ia g n o s e d b y E L IS A o n fe c a l s a m p le s . T h e illn e s s is
c h a r a c t e r iz e d b y v o m itin g , lo w - g r a d e fe v e r , d ia r r h e a , a n d th e m e ta b o lic
c o n s e q u e n c e s o f w a t e r a n d e le c tr o ly te lo s s . R e c o v e r y u s u a lly o c c u r s w ith in 1 2
- 2 4 h o u rs .
Im p o r ta n t: D e h y d r a tio n is a m a jo r c o n c e r n , e s p e c ia lly in in fa n ts w h e r e v ir a l
g a s t r o e n t e r it is is s o m e t im e s fa ta l.
R N A n o n -e n v e lo p e d v ir u s fa m ilie s :
• P ic o r n a v ir u s ( P o lio v ir u s , C o x s a c k ie A & B v ir u s e s , R h in o v ir u s , H e p . A v ir u s )
• R e o v ir u s
• C a lic iv ir u s e s ( in c lu d e s n o r o v ir u s e s a n d s a p o v ir u s e s )
v ir u s 3

W h ic h o f th e fo llo w in g is a p a r a m y x o v ir u s th a t c a u s e s m a n y
r e s p ir a to r y in fe c tio n s in e p id e m ic s e a c h w in te r . It is a c o m m o n c a u s e
o f b r o n c h io litis in in fa n ts , w h ic h is c o m p lic a te d b y p n e u m o n ia in
a p p r o x im a te ly 1 0 % o f c a s e s ?

• in flu e n z a
• r u b e lla
• c o x s a c k ie v ir u s
• r e s p ir a t o r y s y n c y tia l v ir u s ( R S V )

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • re s p ira to ry s y n c y tia l v iru s (R S V )
R S V is th e o n ly m e m b er o f th e p a ra m y x o v iru s fa m ily ( w h ic h a ls o in c lu d e s th e
m e a s le s , m u m p s , a n d p a r a in flu e n z a v iru s e s ) th a t la ck s th e e n v e lo p e g ly c o p ro te in s
h e m a g g lu tin in a n d n e u r a m in id a s e . Its s u rfa c e s p ik e s a re fu s io n (F ) p ro te in s . R S V
c o m m o n ly c a u s e s r e s p ira to r y tra c t in fe c tio n s r a n g in g fro m th e c o m m o n c o ld to
p n e u m o n ia a n d b ro n c h io litis . T h e m o re s e v e re m a n ife s ta tio n s o c c u r in in fa n ts a n d
im m u n o c o m p r o m is e d in d iv id u a ls .
R em em b er: T h e e n v e lo p e o f p a ra m y x o v iru s e s is c o v e re d w ith s p ik e s , w h ic h c o n ta in
e ith e r h e m a g g lu tin in , n e u r a m in id a s e , o r a fu s io n p r o te in th a t c a u s e s c e ll fu s io n a n d , in
s o m e c a s e s , h e m o ly s is .
Its v irio n s u r fa c e p r o te in s c a u s e in fe c te d c e lls to fu s e , fo r m in g m u ltin u c le a te d g ia n t
c e lls ( s y n c y tia l), w h ic h g iv e ris e to th e n a m e o f th e v iru s . T r e a tm e n t is g e n e ra lly
s u p p o rtiv e , b u t a e r o s o liz e d rib a v irin (V ira z o le ) c a n b e g iv e n to s e v e re c a s e s ,
p a r tic u la r ly th o s e w ith u n d e rly in g c a r d ia c o r r e s p ira to r y d is e a s e . N o v a c c in e is
c u r re n tly a v a ila b le fo r R S V .
Note: R S V u n d e rg o e s a n tig e n ic d rift, and c o n s e q u e n tly , r e in fe c tio n can occur
th r o u g h o u t life.
P a ra in flu e n z a v iru s e s c a u s e c ro u p (a c u te la r y n g o tr a c h e o b r o n c h itis ) a n d p n e u m o n ia
in c h ild r e n a n d a d is e a s e r e s e m b lin g th e c o m m o n c o ld in a d u lts . In fe c tio n is lim ite d to
th e r e s p ira to r y tra c t ( u p p e r r e s p ira to r y tra c t d is e a s e is m o s t c o m m o n ). T h e s u rfa c e
s p ik e s p r e s e n t o n th e v iru s e s c o n s is t o f h e m a g g lu tin in (H ), n e u r a m in id a s e (N ), a n d
fu s io n (F) p ro te in s . T h e s e v iru s e s a re tr a n s m itte d b y r e s p ira to r y d r o p le ts a n d d ire c t
c o n ta c t; th e r e is n e ith e r a n tiv ira l th e ra p y n o r a v a c c in e a v a ila b le . Note:
P a r a in flu e n z a v iru s e s ra re ly c a u s e v ire m ia (u n lik e m e a s le s a n d m u m p s v iru s e s ).
Im p o rtan t: In te r s titia l p u lm o n a r y in fla m m a tio n is m ost c h a r a c te r is tic of v ira l
p n eu m o n ia.
P a ra m y x o v iru s e s :
• ss n e g a tiv e R N A
• E n v e lo p e d
• C o n ta in a n R N A -d e p e n d e n t R N A p o ly m e ra s e
• R e s e m b le o rth o m y x o v iru s e s e x c e p t th e y a re u s u a lly la r g e r in s iz e , a n d h a v e
d iffe r e n t s u r fa c e p r o te in s a s w e ll a s n o n s e g m e n te d g e n o m e s
v ir u s 4

W h ic h o f t h e fo llo w in g v ir u s e s s h o w s laten c a n d re q u ir e s a tr ig g e r to
re s u m e r e p lic a tio n ?

• m e a s le s v ir u s
• h e r p e s v ir u s
• m u m p s v ir u s
• n o n e o f th e a b o v e

M IC R O B IO L O G Y /P A T H O L O G Y (IM e n ta ld e c k s
P a rt I • V o lu m e 13 • © 2 0 1 7
 • h e r p e s v ir u s
H e r p e s v ir u s c a u s e s la te n t in fe c tio n , i.e ., th e v ir u s r e m a in s q u ie s c e n t
u n til t r ig g e r e d to r e s u m e r e p lic a tio n . It c a u s e s a c u te in fe c tio n f o llo w e d b y
la te n t in fe c tio n d u r in g w h ic h th e v ir u s r e m a in s in a n o n in f e c t io u s fo r m w it h
p e r io d ic r e a c t iv a t io n a n d s h e d d in g .
T h e r e a r e t h r e e o u t c o m e s w h e n a h o s t is in fe c te d w it h th e v ir u s :
• L y tic in fe c tio n : A t y p e o f v ir a l in fe c tio n w h e r e a v ir u s in fe c ts a c e ll a n d
th e n ly s e s it. T h e v ir u s p r o d u c e s n e w v ir u s p a r t ic le s b y u n d e r g o in g a c y c le
o f r e p lic a tio n a n d r e le a s e s t h e m b y c e ll ly s is . E x a m p le s a r e p o lio in fe c tio n
a n d in flu e n z a in fe c tio n .
• P e r s is te n t in fe c tio n : A t y p e o f v ir a l in fe c tio n w h e r e a v ir u s th a t in fe c ts a
c e ll d o e s n o t ly s e it, b u t r e m a in s v ia b le a n d c o n t in u e s t o r e le a s e v ir u s
p a r tic le s a t a s lo w r a te . It p r o v id e s a r e s e r v o ir o f a c o n t in u o u s s o u r c e o f
in fe c tio n a s th e in fe c te d p e r s o n is a n a s y m p t o m a t ic c a r r ie r o f th e v ir u s . A n
e x a m p le is H e p a titis B in fe c tio n .
• L a te n t in fe c tio n : A t y p e o f v ir a l in fe c tio n w h e r e a v ir u s t h a t in fe c ts a h o s t
c e ll d o e s n o t r e p lic a t e b u t r e m a in s la te n t o r q u ie s c e n t u n til t r ig g e r e d b y
s o m e s ig n a l. O n c e t h e d e f e n s e m e c h a n is m o f th e h o s t is lo w e r e d d u e to
s tr e s s , im m u n o s u p p r e s s io n , o r tr a u m a , a c t iv e v ir a l r e p lic a t io n c o m m e n c e s .
D u r in g la te n t in fe c tio n th e g e n e tic m a te r ia l o f th e v ir u s e it h e r e x is t s in
th e c y to p la s m o f t h e h o s t c e ll (e .g ., h e r p e s v ir u s in fe c tio n ) o r is
in c o r p o r a te d in to th e h o s t g e n o m e (e .g ., h e p a titis B).
v ir u s 5

A ll o f th e fo llo w in g a r e in c lu d e d in th e fa m ih o f H e r p e s v ir u s e s
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N '

• v a r ic e lla - z o s te r v ir u s ( V Z V )
• e p s te in - b a r r v ir u s ( E B V )
• c y t o m e g a lo v ir u s ( C M V )
• c o x s a c k ie v ir u s ( A & B )

M IC R O B IO L O G Y /P A T H O L O G Y (U td e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • c o x s a c k ie v ir u s (A & B)
* * * B o th c o x s a c k ie v ir u s g r o u p A & B a r e in th e p ic o r n a v ir u s fa m ily ( s s RNA,
ic o s a h e d r a l c a p s id , w ith n o e n v e lo p e p r e s e n t)
M e m b e r s o f th e H e r p e s v ir u s fa m ily in c lu d e : h e r p e s s im p le x ty p e s 1 a n d 2,
v a r ic e lla z o s te r v ir u s , E p s te in - B a r r v ir u s , h u m a n h e r p e s v ir u s t y p e s 6 , 7 , a n d 8,
a n d c y to m e g a lo v ir u s . A ll h e r p e s v ir u s e s a r e m o r p h o lo g ic a lly id e n tic a l.
H e rp e s v ir u s e s :
• ds DNA • E n v e lo p e d
• N u c le a r m e m b r a n e • Ic o s a h e d r a l n u c le o c a p s id

Im p o r ta n t: H e r p e s v ir u s e s r e p lic a t e in th e n u c le u s o f th e h o s t c e ll a n d a r e th e
o n ly v ir u s e s to o b t a in t h e ir v ir io n e n v e lo p e s b y b u d d in g fr o m th e h o s t n u c le a r
o r G o lg i m e m b r a n e , n o t th e h o s t p la s m a m e m b r a n e .
T h e h a llm a r k o f a ll h e r p e s v ir u s in fe c t io n s is th e a b ility o f th e v ir u s e s to
e s ta b lis h la te n t ( o r s ile n t) in f e c tio n s t h a t th e n p e r s is t fo r th e life o f th e in d iv id u a l.
H S V -1 m o s t c o m m o n ly r e m a in s la te n t in th e tr ig e m in a l g a n g lio n , H S V -2 m o s t
c o m m o n ly r e m a in s la te n t in th e s a c r a l g a n g lia , V Z V m o s t c o m m o n ly r e m a in s
la t e n t in d o r s a l r o o t a n d c r a n ia l n e r v e g a n g lia . C M V m o s t c o m m o n ly r e m a in s
la t e n t in th e n u c le i o f th e c e lls in th e e n d o th e liu m o f th e a r t e r ia l w a ll a n d in T
ly m p h o c y te s . E B V r e m a in s la t e n t in r e s tin g m e m o r y B ly m p h o c y t e s .
T h r e e o f th e h e r p e s v ir u s e s , h e r p e s s im p le x 1, 2 a n d th e v a r ic e lla - z o s te r v ir u s ,
c a u s e a v e s ic u la r ra s h .
C e r ta in h e r p e s v ir u s e s h a v e o n c o g e n ic p o te n tia l ( c a u s in g c a n c e r ) in h u m a n s .
The E p s te in -B a r r v ir u s is a s s o c ia te d w it h B u r k it t's ly m p h o m a and
n a s o p h a r y n g e a l c a r c in o m a , H u m a n h e r p e s v ir u s ty p e 8 ( K a p o s i's s a r c o m a -
a s s o c ia te d h e r p e s v ir u s ) is s tr o n g ly a s s o c ia te d w ith th e e t io lo g y o f c la s s ic a l a n d
A ID S - r e la te d K a p o s i's s a r c o m a .
D N A e n v e lo p e d v ir u s e s : h e r p e s v ir u s , p o x v ir u s , a n d h e p a d n a v ir u s
v ir u s 6

P rio n s a re th e m o s t r e c e n tly re c o g n iz e d a n d th e s im p le s t in fe c tio u s

a g e n ts , c o n s is tin g o f a s in g le p ro te in m o le c u le .
P r io n s c o n ta in n o n u c le ic a c id a n d t h e r e fo r e n o g e n e tic in fo r m a tio n .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is f a ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y I* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s ta te m e n ts a re tru e
P rio n s a r e in fe c tio u s p r o te in p a r tic le s ( a ty p ic a l v ir u s - lik e a g e n t s ) th a t a r e
c o m p o s e d s o le ly o f p ro te in . T h e y c a u s e c e r ta in “ s lo w ” d is e a s e s s u c h a s
C r e u tz fe ld t- J a k o b d is e a s e , a s e v e r e d e g e n e r a tiv e b r a in d is e a s e c a u s e d b y th e
in g e s t io n o f b e e f fr o m a c o w in fe c te d w ith m a d c o w d is e a s e . N o te : T h e ir a b ilit y
to p r o p a g a te w it h in a h o s t r e lie s o n in d u c in g th e c o n v e r s io n o f e n d o g e n o u s
p rio n p r o te in P r P in to a p r o te a s e - r e s is ta n t is o fo r m P rP .
Im p o r ta n t: P r io n s d o n o t e lic it in fla m m a to r y o r a n tib o d y r e s p o n s e s . U n lik e
v ir u s e s , t h e y a r e r e s is ta n t to a b r o a d r a n g e o f p h y s ic a l a n d c h e m ic a l tr e a tm e n ts
( U V r a d ia tio n , fo r m a ld e h y d e , a n d h e a t u p to 8 0 ° C ).
T h e v ir a l p a r t ic le s , o r v ir io n s , c o n ta in e it h e r s in g le - o r d o u b le - s tr a n d e d D N A o r
R N A ( n e v e r b o th ) th a t is e n c a s e d in a p r o t e in c o a t c a lle d a c a p s id . T h e
c o m b in a tio n o f th e n u c le ic a c id a n d th e p r o te in c a p s id is c a lle d th e
n u c le o c a p s id . T h e y a r e e ith e r n a k e d o r e n v e lo p e d , d e p e n d in g o n w h e th e r
th e c a p s id is s u r r o u n d e d b y a lip o p r o te in e n v e lo p e .
T h e c a p s id is c o m p o s e d o f p o ly p e p tid e u n its c a lle d c a p s o m e r e s . S o m e v ir u s e s
( e .g ., o r t h o m y x o v ir u s e s a n d p a r a m y x o v ir u s e s ) h a v e e n v e lo p e s th a t a r e c o v e r e d
w ith s p ik e s , w h ic h c o n ta in e it h e r h e m a g g lu tin in , n e u r a m in id a s e , o r a fu s io n
p r o t e in t h a t c a u s e s c e ll fu s io n a n d , in s o m e c a s e s , h e m o ly s is .
In c o n tr a s t to b a c te r ia , fu n g i, a n d p a r a s ite s , v ir u s e s a re n o t c e lls ; i.e ., th e y
a r e n o t c a p a b le o f r e p r o d u c in g in d e p e n d e n tly , d o n o t h a v e a n u c le u s , a n d do
n o t h a v e o r g a n e lle s s u c h a s r ib o s o m e s , m it o c h o n d r ia , a n d ly s o s o m e s . V ir u s e s
a r e s m a lle r th a n c e lls a n d c a n n o t b e s e e n in th e lig h t m ic r o s c o p e .
N o te : A lm o s t a ll v ir u s e s a r e h a p lo id ( c o n t a in a s in g le c o p y o f t h e ir g e n o m e ; th e
e x c e p t io n is th e r e t r o v ir u s fa m ily , w h o s e m e m b e r s a r e d ip lo id ) .
V ir o id s c o n s is t s o le ly o f a s in g le m o le c u le o f c ir c u la r R N A w it h o u t a p r o te in
c o a t o r e n v e lo p e . T h e y c a u s e s e v e r a l p la n t d is e a s e s b u t a r e n o t im p lic a te d in
a n y h u m a n d is e a s e .
v ir u s 7

H e rp e s s im p le x v ir u s ty p e 2 is m a in ly s p r e a d th r o u g h s e x u a l c o n ta c t.
It c a n n o t b e s p r e a d fr o m m o th e r to in fa n t d u rin g c h ild b irth .

• b o th s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• t h e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • t h e fir s t s ta te m e n t is tru e , th e s e c o n d is fa ls e
H S V - 2 is m a in ly s p r e a d th r o u g h s e x u a l c o n ta c t, a lth o u g h it c a n b e s p r e a d fr o m
m o th e r t o in fa n t d u r in g c h ild b ir th . M o s t g e n ita l in fe c tio n s a r e H S V - 2 ; H S V -1
p r e d o m in a n tly c a u s e s la b ia l le s io n s . R e m e m b e r : O f a ll o f th e h e r p e s v ir u s e s ,
h e rp e s s im p le x v ir u s e s 1 a n d 2 c a u s e m a n ife s ta tio n s o f r e c u r r e n t in fe c tio n in
o th e r w is e h e a lth y p e o p le .
H e rp e s s im p le x v ir u s ty p e 1 - P r im a r y h e r p e tic g in g iv o s to m a titis
• C a u s e d b y in itia l e x p o s u r e to H S V -1
• T r a n s m it te d fr o m p e r s o n to p e r s o n th r o u g h o r a l s e c r e tio n s
• U s u a lly o c c u r s in a c h ild u n d e r t e n y e a r s o f a g e
• N e a r ly a ll p r im a r y in fe c tio n s a r e o f th e s u b c lin ic a l ty p e , t h e y m a y o n ly h a v e
f lu - lik e s y m p to m s a n d o n e o r tw o m ild s o r e s in th e m o u th w h ic h g o u n n o tic e d
b y th e p a r e n ts
A c u te h e r p e tic g in g iv o s to m a tit is :
• In o th e r c h ild r e n , th e p r im a r y in fe c t io n m ay be m a n if e s te d by a c u te
s y m p to m s
• A c u te s y m p to m s in c lu d e fe v e r ; ir r ita b ility ; c e r v ic a l ly m p h a d e n o p a th y ; fie r y
r e d g in g iv a l tis s u e s ; a n d s m a ll, y e llo w is h v e s ic le s w h ic h r u p t u r e a n d r e s u lt in
p a in fu l u lc e r s o n th e fr e e a n d a tt a c h e d m u c o s a
• T h e m o s t s e r io u s p o t e n tia l p r o b le m in a c h ild w it h th is in fe c tio n is
d e h y d r a tio n d u e to th e c h ild n o t w a n tin g to e a t o r d r in k b e c a u s e o f th e p a in
A d u lt re c u r r e n c e - h e r p e s la b ia lis (“ c o ld s o r e ” )
• F o llo w in g p r im a r y in f e c t io n , th e v ir u s r e m a in s la te n t m o s t c o m m o n ly in th e
t r ig e m in a l g a n g lia
• R e a c tiv a tio n o fte n p ro d u c e s lo c a liz e d p a r a e s th e s ia in th e lip b e fo re th e
a p p e a r a n c e o f a c o ld s o r e
• T h e m o s t c o m m o n s ite o f r e c u r r e n c e in a d u lt s is a lo n g th e v e r m illio n
b o r d e r o f th e lip s ( k n o w n a s h e r p e s la b ia lis o r c o ld s o r e s ) . H e r p e t ic
c o n ju n c tiv itis ( in fe c t io n o f th e e y e is a ls o c o m m o n ) .
v iru s 8

W h ic h o f th e fo llo w in g h e r p e s v ir u s in fe c tio n s c a n b e tr e a te d
p r o p h y la c tic a lly b y a v a c c in e ?

• H S V -1
• H S V -2

• v a r ic e lla - z o s te r v ir u s
• E p s te in - B a r r v ir u s

• c y to m e g a lo v ir u s

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • v a r ic e lla - z o s t e r v ir u s
V Z V p r o d u c e s tw o d is t in c t d is e a s e s , v a r ic e lla ( c h ic k e n p o x ) a n d h e r p e s z o s t e r
( s h in g le s ) . T h e p r im a r y in fe c tio n is c h ic k e n p o x . F o llo w in g r e c o v e r y fr o m
c h ic k e n p o x th e v ir u s r e m a in s la te n t in d o r s a l r o o t a n d c r a n ia l n e r v e g a n g lia .
R e a c tiv a tio n o f in fe c tio n t h e n r e s u lt s in s h in g le s .
A n e ff e c tiv e liv e a t te n u a te d v a r ic e lla v a c c in e is a r o u tin e v a c c in a tio n o f
c h ild h o o d in t h e U n it e d S ta te s . N o te : R e c e n t e v id e n c e s u g g e s t s t h a t
v a c c in a t io n o f a ll a d u lts o v e r th e a g e o f 6 0 , w it h a d o s e h ig h e r th a n t h a t u s e d
f o r c h ic k e n p o x p r o p h y la x is in c h ild h o o d , r e d u c e s s h in g le s - r e la t e d m o r b id ity
a n d p o s t - h e r p e t ic n e u r a lg ia .
R e m e m b e r : T y p ic a lly , H S V - 1 in fe c ts A B O V E t h e w a is t: e y e a n d m o u th
le s io n s . H S V - 2 in fe c ts B E L O W t h e w a is t: g e n ita l le s io n s . N o te : O r a l- g e n ita l
s e x c a n le a d to H S V - 1 b e lo w t h e w a is t a n d H S V - 2 a b o v e t h e w a is t.
1 . P r im a r y in fe c tio n w it h H S V -1 c a n r a n g e fr o m s u b c lin ic a l
( a s y m p to m a tic ) t o s e v e r e s y s t e m ic in fe c tio n s .
2 . C o m p lic a t io n s o f H S V -1 in fe c tio n in c lu d e t r a n s f e r to th e e y e
( d e n d r itic u lc e r a tio n , k e r a titis ) a c u te e n c e p h a litis , s k in in fe c tio n s
s u c h a s h e r p e t ic w h it lo w a n d e r y t h e m a m u lt if o r m e .
3 . D ia g n o s is c a n b e m a d e b y T z a n c k p r e p a r a tio n o f v e s ic u la r f lu id ,
w h ic h t y p ic a lly s h o w s m u lt in u c le a t e d g ia n t c e lls .
4 . S y s te m ic a n tiv ir a l d r u g s ( e .g ., a c y c lo v ir , fa m c ic lo v ir , o r v a la c y c lo v ir )
c a n b e u s e d a s e p is o d ic o r s u p p r e s s iv e th e r a p y .
G e n ita l h e rp e s (c a u s e d by H S V -2 ) m ay have s e r io u s consequences in
p r e g n a n t w o m e n b e c a u s e th e v ir u s c a n b e t r a n s m it t e d to t h e in fa n t d u r in g
v a g in a l d e liv e r y . T h e v ir u s c a n c a u s e d a m a g e t o th e in fa n t's c e n tr a l n e r v o u s
s y s te m a n d / o r e y e s .
v iru s 9

A b a c te r io p h a g e w ith th e a b ilit y to fo r m a s ta b le , n o n d is r u p tiv e

r e la tio n s h ip w ith in a b a c te r iu m is c a lle d a:

• v ir u le n t p h a g e
• p la s m id
• te m p e r a te p h a g e
• phage T4

M IC R O B IO L O G Y /P A T H O L O G Y @ * d e n t a ld e c k s
P a ri I • V o lu m e 1 3 • © 2 0 1 7
 • te m p e ra te p h a g e
It is a b a c t e r io p h a g e w h ic h is c a p a b le o f r e p lic a tio n b y a n a lt e r n a t e m e th o d in
w h ic h th e p h a g e g e n o m e is in c o r p o r a t e d in t o th e b a c t e r ia l c h r o m o s o m e . It
p e r s is t s t h r o u g h m a n y c e ll d iv is io n s o f th e b a c t e r iu m w it h o u t d e s t r o y in g th e
h o s t, in c o n t r a s t t o a v ir u le n t p h a g e t h a t ly s e s a n d k ills its h o s t.
R e m e m b e r th e c h a r a c t e r is t ic s o f a b a c te r io p h a g e : a v ir u s t h a t c a n r e p lic a te
o n ly w ith in s p e c if ic h o s t b a c te r ia l c e lls .
A ly s o g e n ic b a c te r iu m is o n e t h a t c o n t a in s a te m p e r a t e b a c te r io p h a g e .
( E x a m p le : Corynebacterium diphtheriae, s e e b e lo w )
L y s o g e n ic c o n v e r s io n : th e a lt e r a t io n o f a b a c t e r iu m to a v ir u le n t s tr a in b y th e
t r a n s f e r o f a D N A t e m p e r a t e b a c te r io p h a g e . T h e c la s s ic e x a m p le o f th is
c o n v e r s io n is in th e a lte r a tio n o f Corynebacterium diphtheriae to a v ir u le n t
s tr a in . T h e p r e s e n c e o f t h is te m p e r a t e p h a g e r e n d e r s th e b a c te r iu m
p a t h o g e n ic ( w it h o u t th e p h a g e it w o u ld n o t b e h a r m fu l) .

N o te : T h e in te g r a te d v ir a l D N A is c a lle d a p r o p h a g e .

1 . E n t e r o b a c t e r ia p h a g e T 4 is a p h a g e t h a t in fe c ts E. coli b a c te r ia .
2 . P la s m id s a r e e x t r a c h r o m o s o m a l, d o u b le - s t r a n d e d , c ir c u la r D N A
m o le c u le s t h a t a r e c a p a b le o f r e p lic a tin g in d e p e n d e n t ly o f th e
b a c te r ia l c h r o m o s o m e .
v iru s 10

F o r e a c h n u m b e r e d d e fin it io n b e lo w , s e le c t th e m o s t c lo s e ly lin k e d
te r m fr o m th e lis t p ro v id e d .

1. A b a c t e r ia l v ir u s A . B a c te r io p h a g e
2 . A c e ll w ith in w h ic h a v ir u s B . H o s t c e ll
r e p lic a te s
C . L y s o g e n ic c y c le
3 . In te g r a tio n in t o th e h o s t g e n o m e D
D . L y t ic c y c le
w it h o u t k illin g th e h o s t
. ... . ... ,. .... , , „ E . T r a n s d u c tio n
4 . V ir a l m u lt ip lic a tio n w ith in a h o s t c e ll
le a d in g to d e s tr u c tio n
5. T r a n s fe r o f D N A fr o m a d o n o r c e ll
to a r e c ip ie n t c e ll w ith th e D N A
p a c k a g e d w ith in a b a c te r io p h a g e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 1. B a c te r io p h a g e , 2 . H o s t c e ll, 3 . L y s o g e n ic c y c le , 4 . L y tic c y c le , 5.
T r a n s d u c tio n
A b a c t e r io p h a g e is a v e r y d e lic a te b a c te r ia l v ir u s w h ic h m a y a tt a c k a n d
d e s t r o y b a c te r ia l c e lls u n d e r c e r ta in c o n d itio n s . It c o n t a in s a n u c le ic a c id c o r e
w h ic h c a n c o n s is t e it h e r o f D N A o r R N A . T h is c o r e c a n b e e it h e r s in g le -
s t r a n d e d o r d o u b le - s t r a n d e d . T h e n u c le ic a c id c o r e is s u r r o u n d e d b y a p r o te in
c o a t . S o m e b a c t e r io p h a g e s m a y c o n ta in lip id . S o m e h a v e a t a il- lik e s tr u c tu r e
t h r o u g h w h ic h t h e y in je c t th e ir n u c le ic a c id in to th e b a c te r ia l h o s t c e ll. It is a ls o
c a lle d a p h a g e .
A h o s t c e ll is a c e ll w ith in w h ic h a v ir u s r e p lic a te s . O n c e in s id e th e h o s t c e ll,
th e v ir a l g e n o m e a c h ie v e s c o n tr o l o f t h e c e ll's m e ta b o lic a c tiv it ie s . T h e v ir u s
t h e n u s e s t h e m e t a b o lic c a p a c it y o f t h e h o s t c e ll to r e p r o d u c e n e w v ir u s e s .
O ft e n t h e r e p lic a tio n o f t h e s e n e w v ir u s e s c a u s e s d e a th o f t h e h o s t c e ll.
B a c te r io p h a g e in fe c t io n f o llo w s o n e o f tw o c o u r s e s : ly s is o r ly s o g e n y . If th e
in fe c tin g v ir u s m u lt ip lie s w ith in th e h o s t c e ll a n d d e s t r o y s it, t h e v ir u s is s a id to
b e ly tic , o r v ir u le n t. O n t h e o t h e r h a n d , if t h e v ir u s d o e s n o t r e p lic a te b u t
r a th e r in t e g r a t e s in t o th e b a c te r ia l c h r o m o s o m e , t h e v ir u s is s a id to b e
t e m p e r a te , or ly s o g e n ic . T h e phage in th e ly s o g e n ic c y c le can
s p o n t a n e o u s ly b e c o m e ly tic . T h e p r e s e n c e o f th e in te g r a te d v ir u s , w h ic h is
c a lle d a p r o p h a g e , g e n e r a lly r e n d e r s t h e c e ll r e s is ta n t t o in fe c tio n b y s im ila r
p h a g e s . L y s o g e n y d o e s n o t r e s u lt in t h e d e s t r u c t io n o f t h e h o s t c e ll.
R e m e m b e r : T r a n s d u c t io n is th e tr a n s f e r o f D N A fr o m a d o n o r c e ll t o a
r e c ip ie n t c e ll w ith t h e D N A p a c k a g e d w ith in a b a c te r io p h a g e . T r a n s fo r m a tio n
is g e n e t r a n s f e r r e s u ltin g fr o m th e u p ta k e b y a r e c ip ie n t c e ll o f n a k e d D N A
fr o m a d o n o r c e ll. C o n ju g a tio n is t h e e x c h a n g e o f g e n e tic m a te r ia l fr o m o n e
b a c te r ia l c e ll ( d o n o r ) to a n o t h e r ( r e c ip ie n t) b y th e c lo s e a s s o c ia tio n o f th e tw o
c e lls a n d th e p a s s a g e o f th e b a c te r ia l c h r o m o s o m e o r p la s m id th r o u g h th e F
p ilu s .
v ir u s 12

F o r e a c h n u m b e r e d s ite o f la te n c y b e lo w , s e le c t th e m o s t c lo s e ly
lin k e d v ir u s fr o m th e lis t p ro v id e d .

1. S a c r a l G a n g lia A . H S V -2
2 . R e s tin g m e m o r y B ly m p h o c y te s B . E p s te in - B a r r
3 . T r ig e m in a l g a n g lio n C . H S V -1
4 . T ly m p h o c y te s D . C y t o m e g a lo v ir u s
5. D o r s a l r o o t a n d c r a n ia l n e r v e E . V a r ic e lla - Z o s te r
g a n g lia

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 1 .H S V -2
2.
E p s te in -B a r r
3 . H S V -1
4 . C y t o m e g a lo v ir u s
5 . V a r ic e lla - Z o s te r

V iru s U s u a l S ite o f L a te n c y D is e a s e

H S V -1 T r ig e m in a l g a n g lio n P r im a ry : G in g iv o s to m a titis

S e c o n d a ry : C o ld s o re

K e ra titis

E n c e p h a litis

H S V -2 S a c ra l g a n g lia G e n ita l h e rp e s

E p s te in -B a rr R e s tin g m e m o r y B ly m p h o c y te s P rim a ry : In fe c tio u s m o n o n u c le o s is

S e c o n d a r y : B u r k i t t ’s ly m p h o m a *

B c e ll ly m p h o m a *

H a ir y le u k o p la k ia *

N a s o p h a ry n g e a l c a rc in o m a *

‘ A s s o c ia te d w ith

C y to m e g a lo v iru s In th e n u c le i o f th e c e lls in th e C o n g e n ita l in fe c tio n ( i f a m o th e r b e c o m e s

e n d o th e liu m o f th e a r te r ia l w a ll in fe c te d w ith C M V d u rin g p re g n a n c y )

a n d in T ly m p h o c y te s I n f e c tio n in im m u n o c o m p r o m is e d in d iv id u a ls

V a ric e lla -Z o s te r D o rsa l ro o t a n d c ra n ia l n e rv e P rim a ry : C h ic k e n p o x

g a n g lia S e c o n d a ry : S h in g le s
v ir u s 11

R e tr o v ir u s e s c o n ta in a n R N A g e n o m e a n d re v e r s e tra n s c r ip ta s e .
A p ro v ir u s is fo r m e d a s v ira l R N A is d ir e c tly in c o rp o ra te d in to th e h o s t
DNA.

• b o t h s ta te m e n ts a r e tr u e
• b o t h s ta te m e n ts a r e fa ls e
• th e fir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • t h e f ir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
R e t r o v ir u s e s c o n t a in 2 id e n tic a l, s in g le - s t r a n d e d , p o s it iv e - s e n s e RNA
m o le c u le s . T h e y a ls o c o n ta in a n R N A - d ir e c te d D N A p o ly m e r a s e ( r e v e r s e
t r a n s c r ip t a s e ) . O n c e in fe c te d , t h is r e v e r s e tr a n s c r ip t a s e u s e s t h e v ir a l R N A a s
a t e m p la t e t o c r e a t e v ir a l D N A , w h ic h is t h e n in c o r p o r a t e d in to th e h o s t D N A to
fo r m a p r o v ir u s . T h is p r o v id e s th e te m p la t e f o r v ir a l R N A s y n t h e s is b y h o s t -
d e r iv e d m e c h a n is m s .
Im p o r t a n t p o in t to r e m e m b e r : R e t r o v ir u s e s a r e d is t in g u is h e d fr o m o t h e r
R N A v ir u s e s b y t h e ir a b ilit y to r e p lic a t e t h r o u g h a D N A in t e r m e d ia t e u s in g a n
e n z y m e , r e v e r s e t r a n s c r ip ta s e .

H u m a n ly m p h o t r o p h ic r e tr o v ir u s e s :

• L e n tiv ir u s
° H IV -1 w h ic h c a u s e s A ID S
- H IV -2 w h ic h c a u s e s A I D S
• O n c o v ir u s
° H T L V -1 w h ic h c a u s e s a d u lt T c e ll le u k e m ia
° H T L V -2 w h ic h c a u s e s m y e lo p a t h y
Im p o r t a n t p o in ts t o r e m e m b e r :
• F o r R N A v ir u s e s :
° T r a n s c r ip t io n o c c u r s in t h e c y to p la s m e x c e p t f o r r e tr o v ir u s e s and
in f lu e n z a v ir u s e s .
° T r a n s c r ip t io n in v o lv e s a n R N A -d e p e n d e n t R N A p o ly m e r a s e e x c e p t
f o r r e tr o v ir u s e s , w h ic h a s e x p la in e d a b o v e p o s s e s s th e e n z y m e r e v e r s e
tr a n s c r ip t a s e ( a n R N A - d e p e n d e n t D N A p o ly m e r a s e ) .
• F o r D N A v ir u s e s :
» T r a n s c r ip t io n o c c u r s in t h e n u c le u s e x c e p t fo r p o x v ir u s e s .
° T r a n s c r ip t io n in v o lv e s a h o s t-c e ll D N A -d e p e n d e n t RNA
p o ly m e r a s e .
v ir u s 13

A ll o f th e fo llo w in g a r e R N A e n v e lo p e d v ir u s e s E X C E P T o n e . W h ic h
o n e is th e E X C E P T IO N ?

• r u b e lla v ir u s
• in flu e n z a e v ir u s e s A , B , a n d C
• r o ta v ir u s
• m e a s le s v ir u s

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • r o ta v ir u s
H u m a n R N A V iru s e s I H u m a n D N A Vi

V iru s e s F a m ily F 'n v c l o p e V iru s e s F a m ily E n v e lo p e

P o lio v iru s P ic o m a v iru s No A d e n o v iru se s A d e n o v in d a e N o

C o x s a c k ie v iru s
H e rp e s s im p le x v iru s ty p e s 1 H e rp e s v irid a e Y es
E c h o v im s
and 2
H e p a titis A v iru s
V a ric e lla -Z o s te r v iru s
R h in o v in w
C y to m e g a lo v iru s
E n te ro v ir u s 6 8 -7 1
E p s te in -B a rr v iru s

R c o v iru s R c o v in is N o H u m a n h e r p e s v ir u s ty p e 6 , 7

R o ta v iru s and 8

T o g a v in is Y es H e p a titis B v iru s H e p a d n a v irid a e Y es

R u b e lla v iru s
A lp h a v iru s e s P a p o v a v irid a c No
H u m a n p a p illo m a v iru s e s

H e p a titis C F la v iv iru s Y es
V a rio la (s m a llp o x ) v iru s P o x v irid a c Y es

N o ro v iru s C a lic iv iiu s No V a c c in ia v ir u s

S a p t 'v i r u s M o llu s e u m c o n ta g io s u in v ir u s

No E r y lh r o v ir u s B 19 P a rv o v irid a c No
Ilc p c v ir u s H e p a titis E v ir u s

In flu e n z a v iru s e s A , B a n d C O rth o m y x o v ir u s Y es

P a r a in f lu e n z a v ir u s e s 1-4 P a ra m y x o v iru s Y es
M e a s le s v iru s
M u m p s v ir u s
R e s p ir a to r y s y u c y tia l v ir u s

L y s s a v iru s — ra b ie s R h a b d o v iru s Y es

H IV 1 a n d 2 R e tro v iru s Y es

H TLV I and 2

E b o la v iru s F ilo v iru s Y es

H a n ta v ir u s B u n y a v iru s Y es

SA R S C o ro n a v im s Y es
v ir u s 14

H u m a n a d e n o v ir u s e s a re u n lik e ly to ta r g e t th e c e n tr a l n e rv o u s
s y s te m B E C A U S E a d e n o v ir u s e s p re fe r e p it h e lia l c e lls fo r re p lic a tio n .

• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t a n d r e la t e d
• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t b u t N O T r e la te d
• th e s ta te m e n t is c o r r e c t , b u t th e r e a s o n is N O T
• th e s ta te m e n t is N O T c o r r e c t, b u t th e r e a s o n is c o r r e c t
• N E IT H E R th e s ta te m e n t N O R th e r e a s o n is c o r r e c t

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • b oth th e s ta te m e n t and th e reaso n a re co rrec t an d related
A d e n o v ir u s e s a re naked ( n o n - e n v e lo p e d ) m e d iu m - s iz e d v ir u s e s c o m p o s e d o f an
ic o s a h e d ra l n u c le o c a p s id a n d a d o u b le -s tra n d ed lin e a r D N A g e n o m e . T h e y h a v e
s p ik e s ( g ly c o p r o te in a c e o u s p r o je c tio n s th a t in th is c a s e a re h e m a g g lu tin in p r o te in s )
p r o tr u d in g fr o m th e ir s u r fa c e s th a t a re in v o lv e d in th e a d s o r p tio n o r a tta c h m e n t o f th e
v ir u s to e p ith e lia l d e r iv a tiv e s o f th e h o s t. T h e s e v iru s e s fr e q u e n tly c a u s e s u b c lin ic a l
in fec tio n s. In fe c tio n is u s u a lly tr a n s m itte d in d r o p le ts o f r e s p ir a to r y o r o c u la r
s e c re tio n s . D is e a s e s in c lu d e r e s p ir a to r y illn e s s e s ( e s p e c ia lly in c h ild r e n ) ,
c o n ju n c tiv itis , g a s tr o in te s tin a l d is e a s e , u r in a iy tr a c t in fe c tio n s , a n d p h a r y n g itis .

V iru s S tru ctu re

• V irio n : in fe c tio u s , c o m p le te v ir u s p a r tic le : R N A o r D N A a n d p r o te in s
N ote: E n v e lo p e d v ir u s e s h a v e c a rb o h y d ra te s a n d lip id s
• C a p s id : c o m p o s e d o f r e p e a tin g p r o te in s u b u n its ( p r o to m e r s )
° p r o te c t v ira l g e n o m e fro m e x tr a c e llu la r n u c le a s e s
° im p a r t s tr u c tu r a l s y m m e tr y to v ir io n ( ic o s a h e d r a l o r h e lic a l)
° e s s e n tia l fo r th e in fe c tiv ity o f v irio n
° in n a k e d ( n o n - e n v e lo p e d ) v iru s e s , th e c a p s id s e r v e s a s th e a tta c h m e n t
p ro te in th a t b in d s to th e h o s t c e ll r e c e p to r
» a n tig e n ic a n d p r o v o k e h o s t im m u n e r e s p o n s e
° m o s t v ir u s e s h a v e o n e c a p s id , a n e x c e p tio n is R e o v irid a e th a t h a s tw o c a p s id
la y e rs
• N u c le o c a p s id : c o m p o s e d o f c a p s id a n d n u c le ic a c id
• E n v elo p e: v ira l m e m b r a n e , lip id b ila y e r c a rr y in g v ir a l g ly c o p r o te in s
• M atrix p ro tein : w e ld s th e c a p s id o r n u c le o c a p s id to th e e n v e lo p e
1. T h e a b ility o f p a th o g e n ic m ic r o o r g a n is m s , in c lu d in g v ir u s e s , to a tta c h to
a n d in v a d e p a r tic u la r c e lls a n d tis s u e s e s ta b lis h e s s p e c ific tis s u e
a ffin itie s f o r p a th o g e n ic m ic ro o r g a n is m s .
2. M o s t v ira l a n tig e n s o f d ia g n o s tic v a lu e a re p ro tein s.
v ir u s 15

F ro m th e fo llo w in g lis t s e le c t th e F O U R ite m s a s s o c ia te d w ith

p o lio v ir u s .

• r e o v ir id a e
• s a lk v a c c in e

• p o lio m y e litis
• s a b in v a c c in e

• tr a n s v e r s e m y e litis
• p ic o r n a v ir id a e
• M M R v a c c in e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • s a lk v a c c in e , p o lio m y e litis , s a b in v a c c in e , p ic o r n a v ir id a e
P ic o r n a v ir u s e s ( P ic o = s m a ll) a r e a la r g e f a m ily o f s m a ll R N A v ir u s e s , w h ic h
in c lu d e s t h e e n t e r o v ir u s e s , r h in o v ir u s e s , a n d H e p a t it is A v ir u s w h ic h in fe c t
h u m a n s . T h e t e r m e n te r o r e fe r s to th e e n te r ic m e a n s o f s p r e a d o f th e s e
v ir u s e s ( i.e ., v ia th e f e c a l- o r a l r o u te ) . T h e e n te r o v ir u s e s in c lu d e p o lio v ir u s ty p e s
1 - 3 , c o x s a c k ie A a n d B v ir u s e s , e c h o v ir u s e s a n d e n t e r o v ir u s e s 6 8 - 7 1 .
P o lio v ir u s , th e c a u s a tiv e a g e n t o f p o lio m y e litis , is a v e r y s m a ll s in g le - s t r a n d e d
p o s itiv e R N A v ir u s w it h a n ic o s a h e d r a l c a p s id . N o e n v e lo p e is p r e s e n t. T h e
v ir u s p r e f e r e n t ia lly r e p lic a te s in th e m o t o r n e u r o n s o f th e a n t e r io r h o r n o f th e
s p in a l c o r d ; th u s , th e d e a th o f t h e s e c e lls le a d s to m u s c le p a r a ly s is . It is
t r a n s m it t e d b y c o n s u m p t io n o f w a t e r w it h f e c a l c o n t a m in a n t s . It is u n c o m m o n
in th e W e s t e r n w o r ld d u e to s u c c e s s f u l v a c c in a t io n p r o g r a m s .
The in itia l s y m p to m s of p o lio m y e lit is in c lu d e headache, v o m it in g ,
c o n s tip a tio n , a n d s o r e th r o a t. P a r a ly s is m a y f o llo w and is a s y m m e t r ic and
fla c c id .
1. T w o v a c c in e s a r e c u r r e n t ly u s e d f o r a c t iv e im m u n iz a t io n a g a in s t
p o lio m y e litis :
• S a lk v a c c in e c o n t a in in g fo r m a lin - t r e a t e d in a c tiv a te d v ir u s e s th a t
is g iv e n in tr a v e n o u s ly
• S a b in v a c c in e c o n t a in in g liv e , a tte n u a te d v ir u s e s w h ic h is
a d m in is t e r e d o r a lly
* * * B o th c o n t a in 3 - ty p e s o f p o lio v ir u s ( t r iv a le n t) .
v ir u s 16

W h ic h o f th e fo llo w in g is th e la r g e s t a n d m o s t c o m p le x D N A v ir u s ?

• p o x v ir u s fa m ily
• h e r p e s v ir u s fa m ily
• p a p o v a v ir u s fa m ily
• p a r v o v ir u s fa m ily

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • p o x v ir u s fa m ily
T h e p o x v ir u s f a m ily in c lu d e s t h r e e v ir u s e s o f m e d ic a l im p o r ta n c e : s m a llp o x
v ir u s ( v a r io la v ir u s ) , v a c c in ia v ir u s , a n d m o llu s c u m c o n t a g io u s v ir u s ( M C V ) .
P o x v ir u s e s a r e th e la r g e s t a n d m o s t c o m p le x v ir u s e s k n o w n . T h e y h a v e
c o m p le x , o v a l t o b r ic k - s h a p e d m o r p h o lo g y w it h in te r n a l s tr u c tu r e .
P o x v ir u s e s a r e v e r y la r g e ( 3 0 0 n m x 2 0 0 n m ) a n d th e v ir a l g e n o m e c o n s is ts
o f a la r g e , d o u b le - s t r a n d e d , lin e a r D N A t h a t is fu s e d a t b o th e n d s . T h e s e
v ir u s e s m u ltip ly in th e c y to p la s m o f h o s t c e lls ( a s o p p o s e d to th e n u c le u s )
a n d a r e u s u a lly a s s o c ia t e d w it h s k in r a s h e s . T h e m o s t im p o r t a n t h u m a n
p o x v ir u s is s m a llp o x ( v a r io la ) . S m a llp o x is a n a c u te , h ig h ly in fe c tio u s , o f te n
fa ta l d is e a s e t h a t is c h a r a c t e r iz e d b y h ig h fe v e r , p r o s tr a tio n , a n d a v e s ic u la r ,
p u s t u la r r a s h . T h is d is e a s e h a s b e e n e r a d ic a t e d b y g lo b a l u s e o f th e v a c c in e ,
w h ic h c o n t a in s liv e , a tte n u a te d v a c c in ia v ir u s .
„ 1. T h e v ir io n o f p o x v ir u s e s c o n ta in s a D N A -d e p e n d e n t R N A
p o ly m e r a s e . T h is e n z y m e is r e q u ir e d b e c a u s e th e v ir u s r e p lic a te s
in th e c y to p la s m a n d d o e s n o t h a v e a c c e s s t o th e c e llu la r R N A
p o ly m e r a s e , w h ic h is lo c a t e d in th e n u c le u s .
2 . S m a llp o x v ir u s h a s a s in g le , s t a b le s e r o ty p e , w h ic h is th e k e y to
th e s u c c e s s o f th e v a c c in e . If th e a n t ig e n ic it y v a r ie d a s it d o e s in
th e in f lu e n z a v ir u s , e r a d ic a t io n w o u ld n o t h a v e s u c c e e d e d .
3 . H e r p e s v ir u s e s , a d e n o v ir u s e s , p a p o v a v ir u s e s , a n d h e p a d n a v ir u s
a r e o t h e r ic o s a h e d r a l D N A v ir u s e s a n d m u lt ip ly in th e n u c le u s o f
h o s t c e lls .
N o te : P o x v ir u s e s a r e th e o n ly D N A v ir u s e s t h a t r e p lic a t e in th e
c y to p la s m .
v ir u s 17

A ll o f th e fo llo w in g a r e m e m b e r s o f th e P ic o r n a v ir id a e fa m ily E X C E P T
o n e . W h ic h o n e is th e E X C E P T IO N ?

• p o lio v ir u s
• c o x s a c k ie v ir u s
• e n te r o v ir u s
• h e p a d n a v ir u s
• h e p a titis A v ir u s
• r h in o v ir u s

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • h e p a d n a v ir u s
P ic o r n a v ir u s e s ( P ic o = s m a ll) a r e a la r g e fa m ily o f s m a ll ( 3 0 n m ) R N A v ir u s e s ,
w h ic h in c lu d e s th e e n te r o v ir u s e s , r h in o v ir u s e s , a n d H e p a t it is A v ir u s w h ic h
in fe c t h u m a n s . T h e t e r m e n te r o r e fe r s t o th e e n t e r ic m e a n s o f s p r e a d o f th e s e
v ir u s e s ( i.e ., v ia th e fe c a l- o r a l r o u te ) .

T h e e n te r o v ir u s e s in c lu d e p o lio v ir u s t y p e s 1 - 3 , c o x s a c k ie A a n d B v ir u s e s ,
e c h o v ir u s e s a n d e n t e r o v ir u s e s 6 8 - 7 1 .
T h e p ic o r n a v ir u s e s n o n -e n v e lo p e d , a n d a r e c o m p o s e d o f a s in g le -s tr a n d e d
p o s itiv e R N A g e n o m e w it h a n ic o s a h e d r a l c a p s id . N o te : T h e p ic o r n a v ir u s e s
a r e in c a p a b le o f c a u s in g c e ll t r a n s f o r m a t io n , d u e to th e R N A g e n o m e .

C o x s a c k ie v ir u s e s :
• G ro u p A V ir u s : c a u s e h e r p a n g in a a n d h a n d - f o o t - a n d - m o u t h d is e a s e .
V e s ic u la r le s io n s a c c o m p a n y f e v e r , s o r e th r o a t, a n d p a in o n s w a llo w in g .
N o te : T h e lo c a tio n o f o r a l le s io n s d is t in g u is h e s t h e s e tw o d is e a s e s fr o m
o n e a n o th e r ; th e o r a l le s io n s o f h e r p a n g in a a p p e a r o n th e th r o a t, p a la t e , o r
to n g u e ; th e o r a l le s io n s o f h a n d -fo o t-a n d -m o u th d is e a s e a p p e a r o n th e
b u c c a l m u c o s a a n d g in g iv a .
• G r o u p B (fo r b o d y ) V ir u s : f e v e r a n d c h e s t p a in w ith h e a d a c h e , fa tig u e ,
a n d a c h in g m u s c le s la s tin g 4 - 5 d a y s .
1. D is e a s e s a s s o c ia t e d w it h e c h o v ir u s e s in c lu d e : a s e p t ic m e n in g it is ,
e n c e p h a litis , p a r a ly s is , r a s h , fe v e r , a c u te u p p e r r e s p ir a t o r y t r a c t
in fe c tio n s , e n te r itis , p le u r o d y n ia , m y o c a r d it is a n d n e o n a ta l
in fe c tio n s .
2 . R h in o v ir u s e s a r e th e m a in c a u s e o f th e c o m m o n c o ld . T h e r e a r e
m o r e t h a n 1 0 0 s e r o lo g ic ty p e s , w h ic h is th e m a in r e a s o n t h a t a
v a c c in e h a s n o t b e e n fo u n d .
v ir u s 18

A ty p ic a l ly m p h o c y te s a n d a r e a c tiv e h e te r o p h ile a n tib o d y te s t a r e th e

m o s t c o m m o n fin d in g s o f w h ic h o f th e fo llo w in g d is e a s e s ?

• t o x o p la s m o s is
• e n te r ic fe v e r
• in fe c tio u s m o n o n u c le o s is
• e o s in o p h ilia

M IC R O B IO L O G Y /P A T H O L O G Y H f r d e n t a ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • in fe c tio u s m o n o n u c le o s is
In fe c tio u s m o n o n u c le o s is , a ls o k n o w n a s g la n d u la r fe v e r , is a s e lf- lim ite d ,
ly m p h o p r o lif e r a t iv e d is o r d e r . It is c a u s e d b y th e E p s te in -B a r r v ir u s (E B V ) th a t
in fe c ts B c e lls a n d p o s s ib ly e p it h e lia l c e lls o f th e o r o p h a r y n x . It u s u a lly
o c c u r s in c h ild r e n a n d y o u n g a d u lts , w it h p e a k in c id e n c e in th e a g e g r o u p o f
1 5 t o 2 0 y e a r s . T h e d is e a s e is s p r e a d t h r o u g h c lo s e h u m a n c o n t a c t w it h b o d y
s e c r e tio n s , p r im a r ily t h r o u g h s a liv a e x c h a n g e d u r in g k is s in g , h e n c e it is a ls o
k n o w n a s th e k is s in g d is e a s e .
C o m m o n s ig n s a n d s y m p t o m s o f in f e c t io u s m o n o n u c le o s is a r e fe v e r , s o r e
th r o a t, c o u g h , h e a d a c h e , c h ills , n a u s e a o r v o m it in g , a n d b ila te r a l s y m m e t r ic a l
ly m p h a d e n o p a t h y . S p le n o m e g a ly a n d h e p a t it is a r e a ls o c o m m o n .
L a b o r a to r y f in d in g s o f in fe c tio u s m o n o n u c le o s is :
• P e r ip h e r a l b lo o d s m e a r : B lo o d p ic tu r e s h o w s a b s o lu t e ly m p h o c y t o s is
w it h m o r e t h a n 6 0 % o f th e w h it e b lo o d c e lls a s ly m p h o c y t e s . N u m e r o u s
a ty p ic a l ly m p h o c y t e s a r e s e e n , m e a s u r in g 1 2 t o 1 6 p m in d ia m e te r . T h e s e
a ty p ic a l ly m p h o c y t e s h a v e a v a c u o la t e d c y to p la s m w it h c y t o p la s m ic
a z u r o p h ilic g r a n u le s a n d a n o v a l, h o r s e s h o e - s h a p e d , o r in d e n te d n u c le u s .
• P o s itiv e h e te r o p h ile a n tib o d y r e a c tio n ( M o n o s p o t te s t): P r e s e n c e o f
a g g lu t in a t io n o f h o r s e R B C s o n e x p o s u r e t o E B V h e t e r o p h ile a n tib o d ie s .
• R is in g t it e r o f s p e c ific a n tib o d ie s fo r E p s te in -B a r r n u c le a r a n tig e n .
v ir u s 19

H IV -1 a n d th e re la te d v ir u s , H IV -2 a r e fu r th e r c la s s if ie d a s le n tiv ir u s e s
B E C A U S E o f th e ir s lo w ly p r o g r e s s iv e c lin ic a l e ffe c ts .

• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t a n d r e la t e d
• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t b u t N O T r e la te d
• th e s ta te m e n t is c o r r e c t , b u t th e r e a s o n is N O T
• th e s ta te m e n t is N O T c o r r e c t , b u t th e r e a s o n is c o r r e c t
• N E IT H E R th e s ta te m e n t N O R th e r e a s o n is c o r r e c t

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • b o th th e s ta te m e n t a nd th e re as o n a re c o r re c t a nd related
R e t r o v ir u s e s a re R N A v ir u s e s th a t h a v e th e ir g e n o m e s u r r o u n d e d b y a n in n e r p ro te in
e n v e lo p e a n d a n o u te r e n v e lo p e th a t c o n t a in s lip id a n d g ly c o p r o te in s p ik e s , w h ic h
s e rv e to a tta c h th e v ir u s to th e h o s t c e lls . T h e w o r d " r e tr o " r e fe r s to th e p o s s e s s io n o f
th e e n z y m e re v e rs e tra n s c rip ta s e ( a n R N A - d ir e c te d D N A p o ly m e r a s e ) , w h ic h
tr a n s c r ib e s R N A to D N A d u r in g th e p r o c e s s o f v ir a l n u c le ic a c id s y n th e s is .
T h e n u c le o c a p s id o f H IV c o n s is ts o f tw o s in g le s tr a n d s o f R N A a lo n g w ith th e
e n z y m e s re v e rs e tra n s c rip ta s e , p ro te a se , a n d in teg ras e , a ll e n c a s e d in a n o u te r
lip id e n v e lo p e d e r iv e d fr o m a h o s t c e ll v ia b u d d in g . T h is e n v e lo p e h a s 7 2 s u r fa c e
p r o je c t io n s c o n t a in in g a n a n t ig e n , g p 1 2 0 , th a t a id s in th e b in d in g o f th e v ir u s to th e
ta r g e t c e lls w ith C D 4 re c e p to rs . A s e c o n d g ly c o p r o te in , g p 41 , b in d s g p 1 2 0 to th e lip id
e n v e lo p e . T h e g e n o m e o f H IV , s im ila r to r e tr o v ir u s e s in g e n e r a l, c o n t a in s th r e e m ajor
g en es:
• e n v g e n e - c o d e s fo r its tw o e n v e lo p e g ly c o p r o te in s
• pol g en e - c o d e s fo r its t h r e e e n z y m e s
• gag g e n e - c o d e s fo r c o r e p r o te in s
T h e tr a n s m is s io n o f H IV o c c u r s p r im a r ily b y s e x u a l c o n ta c t a n d b y tr a n s fe r o f in fe c te d
b lo o d . T h e v ir u s in f e c t s a n d k ills h e lp e r ( C D 4 ) T -c e lls , r e s u ltin g in th e d e p r e s s io n o f
b o th h u m o r a l a n d c e ll- m e d ia t e d im m u n ity . It tr a v e ls th r o u g h o u t th e b o d y , p a r t ic u la r ly in
m a c ro p h ag e s, w h ic h a r e th e fir s t c e lls in f e c te d b y H IV . It in d u c e s a d is tin c tiv e C P E
( c y to p a t h ic e ffe c t) c a lle d g ia n t-c e ll ( s y n c y tia l) fo rm atio n . In a d d itio n to th e C D 4
r e c e p to r , a c o r e r e c e p to r k n o w n a s a c h e m o k in e is r e q u ir e d fo r H IV to in fe c t c e lls .
Im p o rtan t: T h e r a p id e m e r g e n c e o f n e w s tr a in s o f H IV is p r im a r ily th e r e s u lt o f
fre q u e n t e rro rs in tro d u c e d b y v ira l re v e rs e tra n s c rip ta s e .
1. A c u te HIV-1 p rim a ry in fec tio n c a n p r e s e n t a s a m o n o n u c le o s is -lik e
s y n d ro m e w ith fe v e r , fa tig u e , s o r e th r o a t , a n d s k in ra s h .
2 . H IV d iff e r s fr o m th e R N A tu m o r v ir u s e s in th a t it ly s e s th e h o s t c e lls . R N A
tu m o r v ir u s e s tr a n s fo r m th e c e lls th a t th e y in v a d e b u t d o n o t p o s s e s s
c y to ly tic a c tiv ity .
3. H TLV -1 a n d 2 a r e a ls o r e tr o v ir u s e s th a t a re fu r t h e r c la s s ifie d a s
o n c o v iru s e s .
v ir u s 20

A ll o f th e fo llo w in g v ir u s e s h a v e n e g a tiv e p o la r ity o r c o n ta in n e g a tiv e

s e n s e R N A E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• o r th o m y x o v ir u s e s
• p a r a m y x o v ir u s e s
• r h a b d o v ir u s e s
• r e t r o v ir u s e s

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • r e tr o v ir u s e s
R e tr o v ir u s e s h a v e p o s itiv e p o la r it y , o r in o t h e r w o r d s t h e y p o s s e s s p o s itiv e
s e n s e R N A m o le c u le s ( R N A w it h t h e s a m e b a s e s e q u e n c e a s th e m R N A ) .
R N A w it h n e g a tiv e p o la r ity h a s a b a s e s e q u e n c e t h a t is c o m p lim e n t a r y to
th e m R N A . F o r e x a m p le , if th e m R N A s e q u e n c e is G - U - C - A , a n R N A w ith
n e g a tiv e p o la r it y w o u ld b e C - A - G - U , a n d a n R N A w it h p o s itiv e p o la r ity w o u ld
b e G - U - C - A . N o te : T h is te r m , p o s itiv e o r n e g a tiv e p o la r ity , o n ly r e fe r s t o R N A
v ir u s e s .
Im p o r t a n t p o in ts t o r e m e m b e r : T h e f ir s t s te p in v ir a l g e n e e x p r e s s io n is
m R N A s y n th e s is . T h e p o s itiv e p o la r ity R N A v ir u s e s c a n u s e t h e ir R N A
g e n o m e d ir e c t ly a s m R N A . T h e n e g a tiv e p o la r ity R N A v ir u s e s m u s t
t r a n s c r ib e t h e ir o w n m R N A b y u s in g th e n e g a t iv e s t r a n d a s a t e m p la te .
B e c a u s e th e c e ll d o e s n o t h a v e a n R N A p o ly m e r a s e c a p a b le o f u s in g R N A a s
a t e m p la te , th e v ir u s c a r r ie s its o w n R N A -d e p e n d e n t R N A p o ly m e r a s e . T h e
p o la r it y a n d g e n o m e s t r u c t u r e g o v e r n h o w v ir a l m R N A is g e n e r a t e d a n d
p r o t e in s a r e p r o c e s s e d .
N o te : R N A v ir u s e s h a v e a g e n o m e w h ic h m a y b e s in g le - s t r a n d e d o r d o u b le -
s tr a n d e d , s e g m e n t e d , o r n o n s e g m e n t e d .
v ir u s 21

A m o th e r ta k e s h e r c h ild to th e ir p r im a r y c a r e p h y s ic ia n . T h e c h ild
h a s a re c e n t h is to r y o f m a la is e a n d fe v e r , a n d n o w p r e s e n ts w ith a
w id e s p r e a d ra s h o n h is tr u n k a n d fa c e . T h e m o th e r s ta te s t h a t th e
c h ild h a s r e c e iv e d th e v a c c in ia v a c c in e . T h is c h ild h a s m o s t lik e ly
b e e n in fe c te d w ith :

• v a r io la
• v a r ic e lla - z o s te r

• c y to m e g a lo v ir u s
• h e r p e s s im p le x ty p e 1

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • v a r ic e lla - z o s t e r

V a r ic e lla - z o s t e r v ir u s p r o d u c e s t w o d is t in c t d is e a s e s , v a r ic e lla ( c h ic k e n p o x )
a n d h e r p e s z o s t e r ( s h in g le s ) . T h e p r im a r y in fe c tio n is c h ic k e n p o x . F o llo w in g
r e c o v e r y fr o m c h ic k e n p o x th e v ir u s r e m a in s la te n t in d o r s a l r o o t a n d c r a n ia l
n e r v e g a n g lia . R e a c tiv a tio n o f in fe c tio n th e n r e s u lts in s h in g le s . O f a ll c a s e s o f
c h ic k e n p o x , 9 0 % o c c u r in c h ild r e n u n d e r 9 y e a r s o f a g e . L o c a l le s io n s
( v e s ic le s ) o c c u r in th e s k in a f t e r d is s e m in a t io n o f th e v ir u s t h r o u g h th e b o d y .
T h e s e le s io n s b e c o m e e n c r u s t e d a n d fa ll o f f in a b o u t o n e w e e k . Im p o r ta n t:
T h e a d m in is t r a t io n o f a s p ir in is c o n t r a in d ic a t e d in t h is a n d in o t h e r c h ild h o o d
v ir a l in fe c tio n s . A s p ir in g iv e n t o in f e c t e d c h ild r e n in c r e a s e s th e in c id e n c e o f
R e y e s y n d r o m e , w h ic h c a n c a u s e e n c e p h a lit is a n d liv e r im p a ir m e n t.
S h in g le s ( h e r p e s z o s te r ) is th e r e s u lt o f r e a c tiv a tio n o f a la te n t v a r ic e lla - z o s t e r
v ir u s t h a t r e m a in e d w ith in th e b o d y fr o m a c h ild h o o d c a s e o f c h ic k e n p o x . It is
c h a r a c t e r iz e d b y p a in fu l v e s ic le s t h a t o c c u r o n th e s k in o r m u c o s a l s u r fa c e s
a lo n g th e d is tr ib u tio n o f a s e n s o r y n e r v e . It is u s u a lly lo c a liz e d t o a s in g le
d e rm a to m e , and is m o re com m on in in d iv id u a ls who a re
im m u n o c o m p r o m is e d .
N o te : A d e n o s in e a r a b in o s id e ( v id a r a b in e ) :
• S u p p r e s s e s th e s y n t h e s is o f v a r ic e lla - z o s t e r a n d h e r p e s s im p le x v ir u s e s
• T e n d s to d im in is h n e w le s io n fo r m a t io n a n d th e d u r a tio n o f f e v e r
• P r e v e n ts th e s p r e a d o f th e v ir u s t h r o u g h t h e v is c e r a
R e m e m b e r : T h e v a c c in ia v a c c in e is a h ig h ly e ff e c tiv e im m u n iz in g a g e n t th a t
e n a b le d th e g lo b a l e r a d ic a t io n o f s m a llp o x .
v iru s 22

In flu e n z a v ir u s e s h a v e a ll o f th e fo llo w in g fe a tu r e s E X C E P T o n e .
W h ic h o n e is th e E X C E P T IO N ?

• s in g le - s tr a n d e d D N A
• h e m a g g lu tin in
• n e u r a m in id a s e
• g e n e tic r e a s s o r tm e n t
• lip o p r o te in c o a t

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • s in g le -s tr a n d e d D N A
I n flu e n z a v ir u s e s a r e t h e o n ly m e m b e r s o f t h e o r th o m y x o v ir u s fa m ily . T h e
in f lu e n z a v ir u s is c o m p o s e d o f a u n iq u e s e g m e n te d , n e g a tiv e , s in g le - s tr a n d e d ,
R N A g e n o m e . It is a s p h e r ic a l o r f ila m e n t o u s e n v e lo p e d v ir u s . T h r e e t y p e s o f
in f lu e n z a a r e r e c o g n iz e d ; A , B , a n d C , d is t in g u is h a b le b y t h e n a tu r e o f t h e ir
in te r n a l p r o te in s .
• I n flu e n z a A is g e n e r a lly r e s p o n s ib le fo r p a n d e m ic s a n d e p id e m ic s
• I n flu e n z a B o ft e n c a u s e s s m a lle r o r lo c a liz e d a n d m ild e r o u tb r e a k s , s u c h
a s in c a m p s o r s c h o o ls
• I n flu e n z a C c a u s e s m ild u p p e r r e s p ir a to r y t r a c t illn e s s . L o w e r r e s p ir a to r y
t r a c t c o m p lic a t io n s a r e r a r e .
T h e e n v e lo p e is c o v e r e d w ith tw o d iff e r e n t t y p e s o f s p ik e s . H e m a g g lu tin in (H ),
a s u r fa c e g ly c o p r o te in , a id s a t t a c h m e n t o f t h e v ir u s t o t h e c e ll w a ll o f
s u s c e p t ib le h o s t c e lls a t s p e c ific r e c e p t o r s ite s . T h e e n z y m e n e u r a m in id a s e
(N ), fa c ilit a t e s c e ll p e n e tr a tio n , p r o b a b ly b y p in o c y to s is , a n d r e le a s e o f
r e p lic a te d v ir u s e s fr o m t h e c e ll s u r f a c e e ff e c te d b y b u d d in g th r o u g h t h e c e ll
m e m b r a n e . T h e a b ilit y o f t h e in flu e n z a v ir u s to c a u s e e p id e m ic s is
d e p e n d e n t o n a n tig e n ic c h a n g e s in t h e h e m a g g lu t in in a n d n e u r a m in id a s e .
T h e r e a r e tw o ty p e s o f c h a n g e s : a n tig e n ic s h if ts , w h ic h a r e m a jo r c h a n g e s
b a s e d o n r e a s s o r tm e n t o f g e n o m e p ie c e s , a n d a n tig e n ic d rifts , w h ic h a r e
m in o r c h a n g e s b a s e d o n p o in t m u ta tio n s .
Im p o r ta n t: R eye s y n d ro m e in c lu d e s v o m itin g , le th a r g y and m ay r e s u lt in
c o m a . It is r a r e , b u t a p p r o x im a t e ly 4 0 % o f c a s e s a r e fa ta l. T h e o r ig in o f R e y e 's
s y n d r o m e is u n c le a r b u t s e e m s t o f o llo w c e r ta in v ir a l in fe c tio n s s u c h a s
in flu e n z a o r c h ic k e n p o x ( v a r ic e lla - z o s te r /h e r p e s z o s te r ) , e s p e c ia lly if th e y a r e in
th e y o u n g a n d e s p e c ia lly if th e y h a v e b e e n t r e a t e d w it h a s p ir in . A s p ir in is
c o n t r a in d ic a te d f o r c h ild h o o d o r a d o le s c e n t fe v e r s b e c a u s e it is a r is k f a c t o r
in th e d e v e lo p m e n t R eye s y n d ro m e . A c e t a m in o p h e n and Ib u p r o fe n a re
a p p a r e n tly n o t a s s o c ia t e d w it h R e y e s y n d r o m e .
v ir u s 23

F o r e a c h n u m b e r e d c h a r a c te r is tic b e lo w , s e le c t th e m o s t c lo s e ly
lin k e d d is o r d e r fr o m th e lis t p ro v id e d .

1. p a in fu l s w e llin g o f th e p a r o tid A . m e a s le s
g la n d s
B. m u m p s
2 . s k in r a s h w ith K o p lik ’s s p o ts C . in flu e n z a
3 . flu - lik e s y m p to m s a n d D . r u b e lla
ly m p h a d e n o p a th y fo llo w e d b y a r a s h
o n th e e n tir e b o d y E . p h a r y n g itis

4 . in fla m m a tio n o f th e p h a r y n x
5 . c o m p lic a tio n s in c lu d e R e y e ’s
S y n d ro m e

M IC R O B IO L O G Y /P A T H O L O G Y C ^ d e n ta ld e c k s
P a rt I - V o lu m e 1 3 - © 2 0 1 7
 1. m u m p s, 2. m e a s les , 3. ru b ella , 4. p h ary n g itis , 5. in flu e n za

1. M u m p s is c a u s e d b y a n R N A p a ra m y x o v iru s a n d is tr a n s m itte d v ia
r e s p ir a to r y d r o p le ts . T h e m o s t n o tic e a b le s y m p to m o f m u m p s is th e
p a in fu l s w e llin g o f th e p a r o tid g la n d s , e ith e r u n ila te r a l o r b ila te r a l. N o te:
T w o c o m p lic a tio n s a re o f s ig n ific a n c e : o rc h itis w ith p a in fu l s w e llin g o f
th e te s tic le s in p o s tp u b e r ta l m a le s , w h ic h c a n r e s u lt in s te r ility , a n d
d eafness in c h ild r e n .
2. In flu e n z a is c a u s e d b y in flu e n z a v iru s e s A , B, a n d C ( o r th o m y x o v ir u s e s ).
C o m p lic a tio n s in c lu d e R eye's s y n d ro m e in c h ild r e n . A m a n ta d in e an d
rim a n ta d in e a c t to p r e v e n t v ira l re p lic a tio n a n d a r e o n ly e ffe c tiv e a g a in s t
in flu e n z a A.
3. M ea s les ( R u b e o la ) is c a u s e d b y r u b e o la v iru s ( R N A p a r a m y x o v iru s ) . It
c h a ra c te r iz e d b y s k in ra s h w ith K o p lik 's sp o ts, a n d is tr a n s m itte d v ia
r e s p ir a to r y d r o p le ts .
4. G e rm a n m e a s les ( R u b e lla ) is c a u s e d b y th e r u b e lla v ir u s ( R N A v ir u s ) .
T ra n s m itte d v ia r e s p ir a to ry d ro p le ts . F lu - lik e s y m p to m s a n d
ly m p h a d e n o p a th y , fo llo w e d b y a ra s h o n th e e n tire b o d y .
5. P h a ry n g itis is a n in fla m m a tio n o f th e p h a r y n x . T h e m a in s y m p to m is a
s o re th ro a t. It is c a u s e d b y a v a r ie ty o f v iru s e s ( a d e n o v iru s e s a n d
c o x s a c k ie v ir u s e s ) .
6. T h e a lp h a v iru s e s ( m e m b e r o f T o g a v ir u s fa m ily ) a n d fla v iv ir u s e s (i.e .,
Y e llo w fe v e r v ir u s , D e n g u e v iru s , W e s t N ile v iru s ) a r e c la s s ifie d a s
a rb o v iru s e s b e c a u s e th e y a r e u s u a lly s p r e a d b y a rth r o p o d v e c to r s .
R e m e m b e r: R h in o v ir u s e s a r e th e m o s t im p o r ta n t c a u s e o f th e c o m m o n c o ld a n d
u p p e r r e s p ir a to r y tr a c t in fe c tio n s . S u c h in fe c tio n s a re s e lf-lim ite d , h o w e v e r , a n d d o
n o t c a u s e s e r io u s d is e a s e . M o re th a n 1 0 0 s e r o ty p e s o f r h in o v iru s h a v e b e e n
id e n tifie d . R h in o v ir u s e s a r e m e m b e r s o f th e p ic o rn a v iru s fa m ily , w h ic h h a v e s in g le -
s tr a n d e d p o s itiv e s e n s e R N A g e n o m e , w ith a n ic o s a h e d ra l c a p s id . N o e n v e lo p e is
p r e s e n t. N o te : O th e r a g e n ts lik e ly to c a u s e th e s y m p to m s o f th e c o m m o n c o ld a re
e n te r o v ir u s e s , c o r o n a v ir u s e s , a d e n o v iru s e s , a n d p a r a in flu e n z a v iru s e s .
v ir u s 24

W h ic h o f th e fo llo w in g m a c r o m o le c u le s is N O T s y n th e s iz e d d u rin g
r e p lic a tio n o f a v ir u s ?

• e a r ly m R N A
• la te m R N A
• g e n e s f o r e n z y m e s a n d n u c le ic a c id b in d in g p r o te in s
• s tr u c tu r a l p r o te in

• im m u n o g lo b u lin - lik e r e c e p to r

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c l< s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • im m u n o g lo b u lin - lik e r e c e p to r
M a c r o m o ie c u la r s y n th e s is , a n im p o r t a n t s te p in th e v ir u s r e p lic a tio n
c y c le , c o n s is t s o f t h e fo llo w in g :
• S y n th e s is o f e a r ly m e s s e n g e r R N A ( m R N A ) is p iv o ta l f o r b in d in g to
r ib o s o m e s a n d t r a n s la t io n in to p r o te in s . G e n e r a lly , m R N A f o r n o n s tr u c tu r a l
p r o t e in s is tr a n s c r ib e d fir s t.
• S y n t h e s is o f n o n s tr u c tu r a l p r o te in s c o n s is t s o f s y n t h e s is o f g e n e s fo r
e n z y m e s ( v ir u s - e n c o d e d p o ly m e r a s e s ) a n d n u c le ic a c id b in d in g p r o te in s .
T h e s e e a r ly g e n e p r o d u c ts ( n o n s tr u c tu r a l p r o te in s ) a r e c a t a ly t ic a n d o n ly a
f e w in n u m b e r a r e r e q u ir e d .
• R e p lic a tio n o f v ir a l g e n o m e : In v ir u s e s , th e g e n o m e is a s in g le n u c le ic
a c id m o le c u le ( e it h e r R N A o r D N A , n e v e r b o th ) t h a t t r a n s la t e s in to a la r g e
m u lt if u n c t io n a l p r o te in , w h ic h is t h e n c le a v e d in to a n u m b e r o f d is t in c t
p r o te in s . A ll D N A v ir u s e s ( e x c e p t p o x v ir u s e s ) r e p lic a te in t h e n u c le u s u s in g
h o s t c e ll R N A p o ly m e r a s e . A lm o s t a ll R N A v ir u s e s ( e x c e p t r e tr o v ir u s e s a n d
o r t h o m y x o v ir u s e s ) r e p lic a te in t h e c y to p la s m .

• S y n th e s is o f la te v ir a l m R N A a n d s tr u c tu r a l p r o te in s : N e w ly r e p lic a t e d
g e n o m e s e r v e s a s t e m p la t e s t o a m p lify la te g e n e m R N A s y n th e s is . L a te
m R N A g e n e s e n c o d e t h e s t r u c t u r a l a n d o t h e r p r o t e in s in t h e v ir u s .

• P o s ttr a n s la tio n a l m o d ific a tio n o f p r o te in is a m e a n s o f m o d u la tin g ,

a c tiv a tin g , or in a c t iv a t in g p r o t e in s th r o u g h m o d if ic a t io n s such as
p h o s p h o r y la tio n , g ly c o s y la tio n , a c y la tio n , o r s u lfa tio n . P h o s p h o r y la t io n is
a c c o m p lis h e d b y c e llu la r o r v ir a l p r o te in k in a s e s . M a n y h e r p e s v ir u s e s
e n c o d e th e ir o w n p r o te in k in a s e s .
v ir u s 25

F o r e a c h c h a r a c te r is tic o n th e le ft, s e le c t th e m o s t c lo s e ly lin k e d

a s s o c ia te d te rm fr o m th e lis t o n th e rig h t.

1. V ir u s t h a t in fe c ts Escherichia coli A . S a te llit e v ir u s

2 . W h e n a v ir u s e n te r s a c e ll b u t d o e s B . V ir o id
n o t r e p lic a te im m e d ia te ly q R e tr o v ir u s
3. D e fe c t iv e v ir u s t h a t r e q u ir e s h e lp e r q
Lam bda
v ir u s to in f e c t th e h o s t c e ll '
Lysogeny
4 . S in g le - s tr a n d e d n a k e d c ir c u la r
RNA
5. C o n s is t o f b o th R N A a n d D N A
v e r s io n s o f th e g e n o m e

M IC R O B IO L O G Y /P A T H O L O G Y m u te n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • 1. D, 2. E, 3 . A , 4 . B, 5. C
Lam bda is a b a c t e r io p h a g e ( v ir u s th a t in fe c ts b a c te r ia ) th a t id e n tifie s a n d
in fe c t s th e b a c t e r ia Escherichia coli a n d in te g r a te s it s e lf in to a s p e c ia l s e q u e n c e
D N A o n th e h o s t c h r o m o s o m e , k n o w n a s th e la m b d a a tta c h m e n t s ite .
L y s o g e n y o r la te n c y is a ty p e o f v ir a l in fe c tio n in w h ic h a v ir u s b e c o m e s
in a c tiv e , d o e s n o t r e p lic a t e b u t d iv id e s its g e n o m e in s te p w it h th e h o s t
c h r o m o s o m e . T h e h o s t c e ll in h a b ite d b y s u c h a v ir u s is c a lle d a ly s o g e n . T h e
te r m s la te n c y a n d ly s o g e n y a r e s y n o n y m o u s , b u t la te n c y is u s e d in r e s p e c t to
a n im a l c e lls a n d ly s o g e n y w it h r e s p e c t to b a c te r ia . W h e n la te n c y o r ly s o g e n y
r e s u lts fr o m th e in te g r a tio n o f th e v ir u s D N A in to a h o s t c e ll c h r o m o s o m e , th e
in t e g r a te d v ir u s D N A b e c o m e s a c o m p o n e n t o f th e h o s t c h r o m o s o m e a n d
r e p lic a te s w h e n th e c h r o m o s o m e s d iv id e . S u c h a n in t e g r a te d v ir u s is k n o w n as
a p r o v ir u s o r , in th e c a s e o f b a c te r ia l v ir u s e s , a p r o p h a g e .
S a te llit e v ir u s is a n in c o m p le te , d e fe c tiv e D N A o r R N A v ir u s th a t r e q u ir e s a
h e lp e r v ir u s to p r o v id e e s s e n tia l g e n e p r o d u c ts f o r its fu n c tio n . T h e h e lp e r v ir u s
s u p p lie s r e p lic a s e , c a p s id p r o t e in s , o r o th e r e s s e n tia ls th a t a llo w s th e s a t e llite
v ir u s to th r iv e in s id e h o s t c e lls .
V ir o id is a s m a ll, n a k e d , in fe c tio u s s in g le -s tr a n d e d R N A a g e n t th a t is n o t
e n v e lo p e d b y a n y p r o te c tiv e la y e r ( p r o te in c o a t) . It r e p lic a te s in s id e in f e c t e d
p la n t c e lls a n d d o e s n o t e n c o d e a n y p r o t e in s . It p o s s e s s e s s e lf- c le a v in g
r ib o z y m e a c tiv ity .
R e tr o v ir u s is u n iq u e in th a t it p o s s e s s e s b o th R N A a n d D N A v e r s io n s o f its
g e n o m e . A r e tr o v ir u s p o s s e s s e s s in g le - s tr a n d e d R N A w it h in tw o p r o te in s h e lls
c o v e r e d b y a n o u te r e n v e lo p e la y e r . T h e e n v e lo p e is d e r iv e d fr o m th e c e ll
m e m b r a n e o f its p r e v io u s h o s t c e ll. A r e tr o v ir u s m a k e s a d o u b le - s tr a n d e d D N A
g e n o m e a ft e r e n te r in g th e h o s t c e ll fr o m its R N A te m p la te w it h th e h e lp o f a n
e n z y m e r e v e r s e tr a n s c r ip ta s e . T h e r e tr o v ir u s D N A is fin a lly in c o r p o r a te d in to
th e h o s t c e ll D N A . T h e c la s s ic e x a m p le o f a r e tr o v ir u s is th e h u m a n
im m u n o d e fic ie n c y v ir u s th a t c a u s e s H IV /A ID S .
v ir u s 26

E a c h o f th e fo llo w in g v ir u s e s c r o s s th e p la c e n ta E X C E P T o n e . W h ic h
o n e is th e E X C E P T IO N ?

• r u b e lla
• h e rp e s
•H IV
• m e a s le s
• c y to m e g a lo v ir u s

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
• m e a s le s
v ir u s 27

T h e r u b e lla v ir u s th a t c a u s e s G e r m a n m e a s le s b e lo n g s to w h ic h o f
th e fo llo w in g v ir u s fa m ilie s ?

• T o g a v ir id a e
• H e r p e s v ir id a e

• O r th o m y x o v ir u s g r o u p
• P a r a m y x o v ir u s g r o u p

M IC R O B IO L O G Y /P A T H O L O G Y (gjt d e n t a l d e c k s
P a r t I 'V o lu m e 1 3 * © 2 0 1 7
 • T o g a v ir id a e
T h e r u b e lla v ir u s th a t c a u s e s r u b e lla , a ls o k n o w n a s G e r m a n m e a s le s ,
b e lo n g s t o t h e T o g a v ir id a e fa m ily a n d R u b iv ir u s g e n u s . It is a n e n v e lo p e d ,
s in g le - s t r a n d e d R N A v ir u s w it h a s in g le a n t ig e n ic ty p e .
R u b e lla s p r e a d s th r o u g h d r o p le t t r a n s m is s io n w ith p e a k in c id e n c e in w in t e r
a n d e a r ly s p r in g . T h e v ir u s f ir s t e n te r s th e n a s o p h a r y n x a n d r e p lic a t e s th e r e ,
a n d s p r e a d s t o th e ly m p h n o d e s . T h is is fo llo w e d b y s u b s e q u e n t v ir e m ia
in v o lv in g t h e p la c e n ta a n d o t h e r o r g a n s .
G e r m a n m e a s le s is c h a r a c te r iz e d b y t h e p r e s e n c e o f a g e n e r a liz e d p in k to
re d m a c u lo p a p u la r r a s h th a t r e m a in s f o r 1 t o 3 d a y s . T h e r a s h a p p e a r s fir s t
o n t h e f a c e a n d s p r e a d s t o t h e n e c k , tr u n k , a n d e x tr e m it ie s . O t h e r s y m p t o m s
in c lu d e ly m p h a d e n o p a t h y , a r t h r o p a t h y , a n d c o n ju n c t iv it is . In a d u lts , th e
p r o d r o m a l p h a s e o f h e a d a c h e , m a la is e , s o r e th r o a t , c o r y z a , a n d lo w g r a d e
f e v e r la s ts u p t o 1 to 6 d a y s , a n d t h e s y m p t o m s d is a p p e a r w it h in 2 4 h o u r s
a f t e r th e s k in e r u p tio n .
M a jo r c o m p lic a t io n s o f r u b e lla a re e n c e p h a litis , a r th r it is , t h r o m b o c y t o p e n ia ,
a n d fe ta l d a m a g e .
b a c te r ia 28

A ll o f th e fo llo w in g a re c h a r a c te r is tic s o f S ta p h y lo c o c c u s a u re u s
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• c o a g u la s e - n e g a tiv e

• g r a m - p o s it iv e
• c a u s e s in fe c tiv e e n d o c a r d it is

• p o s s e s s e s s u r fa c e p r o te in A
• c a u s e s t o x ic s h o c k s y n d r o m e

M IC R O B IO L O G Y /P A T H O L O G Y tM e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • c oag u lase-neg ative
***Staphylococcus aureus is co a gu las e p o sitive w h e re a s o th e r S ta p h y lo c o c c i a re
co ag u lase negative.
Staphylococcus aureus c an n o t invade th ro u g h in ta c t s k in o r m u c o u s m e m b r a n e s , a n d
in fe c tio n u s u a lly b e g in s w ith trau m a tic ino cu latio n o f th e o rg a n is m . O n c e in s id e th e
b o d y , it s e c re te s a n u m b e r o f e n z y m e s a n d to x in s th a t h a rm m o s t tis s u e s .
Note: T h e c e ll w a ll o f S. aureus c o n ta in s rib itol p h o sp h ate te ic h o ic acid.
S. aureus a re p y o g e n ic g r a m - p o s itiv e c o c c i th a t fo r m c lu s te r s lik e b u n c h e s o f g ra p e s .
T h e s e b a c te ria c a u s e a m y ria d o f s k in le s io n s (b o ils , c a rb u n c le s , im p e tig o , a n d s c a ld e d -
s k in s y n d r o m e ) a s w e ll a s a b s c e s s e s , s e p s is , o s te o m y e litis , p n e u m o n ia , e n d o c a rd itis , fo o d
p o is o n in g , a n d to x ic s h o c k s y n d r o m e (T S S ).
S. aureus p ro d u c e s m a n y toxin s, in c lu d in g fiv e c y to ly tic o r m e m b r a n e - d a m a g in g to x in s
(a lp h a , b e ta , d e lta , g a m m a , a n d P a n to n -V a le n tin e [P -V ] le u k o c id in ) , tw o e x fo lia tiv e to x in s
(A a n d B ), e ig h t e n te ro to x in s (A to E, G a n d I) a n d to x ic s h o c k s y n d r o m e to x in -1 ( T S S T -1 ).
Im portant: E x fo lia tiv e to x in A, th e e n te ro to x in s , a n d T S S T -1 b e lo n g to a c la s s of
p o ly p e p tid e s know n as sup eran tig ens. T h e s e to x in s b in d to c la s s II m a jo r
h is to c o m p a tib ility c o m p le x m o le c u le s o n m a c r o p h a g e s , w h ic h in tu rn in te r a c t w ith s p e c ific
T c e ll r e c e p to rs . T h is r e s u lts in a m a s s iv e re le a s e o f cytokin es b y b o th m a c r o p h a g e s a n d
T c e lls .
S. aureus s tr a in s p o s s e s s tw o fo rm s o f coagulase: b o u n d a n d fr e e . C o a g u la s e b o u nd to
th e s ta p h y lo c o c c a l c e ll w a ll c a n d ir e c tly c o n v e r t fib rin o g e n to in s o lu b le fib rin a n d c a u s e
s ta p h y lo c o c c i to c lu m p . T h e cell-free c o a g u la s e a c c o m p lis h e s th e s a m e r e s u lt b y r e a c tin g
w ith a g lo b u lin p la s m a fa c to r ( c o a g u la s e -r e a c tin g fa c to r ) to fo r m s ta p h y lo th r o m b in , a
th ro m b in - lik e fa c to r. T h is fa c to r c a ta ly z e s th e c o n v e rs io n o f fib r in o g e n to in s o lu b le fib rin .
Note: T h is p ro c e s s m a y p ro te c t th e o rg a n is m s fr o m p h a g o c y to s is .
S ta p h y lo c o c c i p ro d u c e a v a rie ty o f o th e r e n z y m e s th a t h y d r o ly z e h o s t tis s u e c o m p o n e n ts
a n d a id in th e s p re a d o f th e b a c te ria . H yaluro n idase h y d r o ly z e s h y a lu r o n ic a c id s , p r e s e n t
in th e a c e llu la r m a tr ix o f c o n n e c tiv e tis s u e . F ibrino lysin, a ls o c a lle d stap h ylo kin ase, c a n
d is s o lv e fib rin c lo ts . A ll s tr a in s o f S. aureus a n d m o re th a n 3 0 % o f th e s tr a in s o f c o a g u la s e
- n e g a tiv e S ta p h y lo c o c c u s p ro d u c e s e v e r a l d iffe r e n t lipases, w h ic h h y d r o ly z e lip id s a n d
e n s u re th e s u rv iv a l o f s ta p h y lo c o c c i in th e s e b a c e o u s a re a s o f th e b o d y . S. aureus a ls o
p ro d u c e s a th e r m o s ta b le nuclease, w h ic h c a n h y d r o ly z e v is c o u s D N A .
b a c te r ia 29

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith

S ta p h y lo c o c c u s aureu s.

• p r o te in A
• s tr e p to k in a s e
• c a u s e s to x ic s h o c k s y n d r o m e
• M p r o te in
• s t r e p to ly s in O
• c a u s e s s c a ld e d s k in s y n d r o m e
• g a s g a n g re n e

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
• p r o te in A , c a u s e s t o x ic s h o c k s y n d r o m e , c a u s e s s c a ld e d s k in
s y n d ro m e
O r g a n is m M a j o r V ir u le n c e F a c t o r (s) A c tio n (s )/D is c a s c (s )

S tre p to c o c c u s M p ro te iu R e s is ta n c e to p h a g o c y to s is

pyogenes D N a s e s A to D C le a v e s D N A

4 S tre p to c o c c a l p y ro g e n ic e x o to x in s (S p e ) R e s p o n s ib le f o r m a n y o f th e c lin ic a l m a n if e s ta tio n s o f

(S p e A , B . C a n d F) s e v e r e s tr e p to c o c c a l d is e a s e s ( ! .e „ s c a r l e t fe v e r)

S tre p to ly s in O a n d S L y s is o f re d & w h ite b lo o d c e lls

S tre p to k in a s e A and B D is s o lv e s fib r in in b lo o d c lo ts

1ly a lu r o n iiln s e B r e a k s d o w n h y a lu ro n ic a c id

E x o to x in A (S p eA ) S tre p to c o c c a l to x ic s h o c k s y n d r o m e
E x o to x in B (S p e B ) R a p id ly d e s tr o y s tis s u e

S ta p h y lo c o c c u s l “r o t c i n A I n h ib its c o m p le m e n t fix a tio n b y b in d in g to th e F c

a u re u s p o r tio n o f lg G

C o a g u lo s c , n u c le a s e , lip a s e s C lo ts b lo o d ; h y d r o ly z e D N A ; h y d ro ly z e lip id s

S tn p h y lo k in a s e ( fib rm o ly s in ) D is s o lv e s b lo o d c lo ts

H y a lu ru n id a s c (s p re a d in g fa c to r) B re a k s d o w n h y a lu ro n ic a c id

B e ta -la c ta m a s e (p e n ic illin a s e ) In a c tiv a te s p e n ic illin

T o x in s :
5 C y t o l y t i c t o x i n s ( a lp h a , b e t a , d e lU i, T o x ic to m a n y ty p e s o f c e lls , in c lu d in g e r y th r o c y te s .

g a m m a , a n d P -V le u k o c id in ) le u k o c y te s , h e p a to c y te s , a n d p la te le ts

8 E n te ro to x im (A to E , G a n d I) C a u s e s fo o d p o is o n in g

2 E x fo lia tiv e to x in s ( A a n d B ) C a u s e s “ s c a ld e d s k in s y n d r o m e ”

T S S T - 1 ( to x ic s h o c k s y n d r o m e to x in ) C a u s e s “ to x ic s h o c k s y n d r o m e "

C lo s trid iu m B o tu lin u m n c u ro to x in : M u s c le a n d n e rv e p a ra ly s is

b o tu lin u m is th e m o s t p o te n t to x in k n o w n to m a n B o tu lis m

C lo s trid iu m P o te n t e x o to x ln : D e s tro y s in te g rity o f c e ll m e m b ra n e ; b r e a k s d o w n

p e rfrin g e n s a - to x in (a le c ith in n s e ) fib r o u s tis s u e

G as g a n g re n e

C l o s tr id iu m te ta n i N c u r o to x in : te ta n u s to x in In te r f e r e s w ith m o to r n e u ro n s

(te ta n o s p a s m ) T e ta n u s (lo c k ja w )

C o r y n c b a c tc riu m D ip h th e ria to x in B lo c k s e lo n g a tio n la c to r - 2 d u r in g tr a n s la tio n .

d ip th c r ia c in h ib itin g p r o te i n s y n th e s is
D ip h th e ria
b a c te r ia 30

W h ic h o f th e fo llo w in g is th e p r e d o m in a n t ty p e o f b a c te r ia o n th e
s k in ?

• la c to b a c illi
• la c t ic a c id b a c t e r ia
• n e is s e r ia
• s t a p h y lo c o c c i

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 s ta p h y lo c o c c i

P re d o m in a n t B a c te ria a t V a r i o u s A n a to m ic a l L o c a tio n s in A d u lts

A n a to m ic a l L o c a tio n P re d o m in a n t b a c te ria

S k in S ta p h y lo c o c c i a n d c o r y n c b a c tc r ia

C o n ju n c tiv a S p a rs e : g ra m - p o s itiv e c o c c i a n d g ra m n e g a tiv e ro d s

O r a l c a v ity :

T e e th S tr e p to c o c c i, lu c to h a c iili

M u c o u s m e m b ra n e s S tr e p to c o c c i a n d la c tic a c id b a c te r ia

U p p e r r e s p ir a to ry tr a c t

N a rc s (n a sa l m e m b ra n e s) S ta p h y lo c o c c i a n d c o r y n e b a c te ria

P h a ry n x (th ro a t) S tr e p to c o c c i, n e is s e r ia . G r a m -n e g a tiv e ro d s a n d c o c c i

L o w e r re s p ir a to ry tra c t N one

G a s tr o in te s tin a l tr a c t

S to m a c h H e lic o b a c te r p y lo ri (u p to 5 0 % )

S m a ll in te s tin e L a c tic s , e n te r ic s , e n te r o c o c c i, b if id o b a c te r ia

C o lo n B a c te r o id e s , l a c tic s , e n te r ic s , e n te r o c o c c i, C lo s tr id ia

U r o g e n ita l tr a c t

A n te r io r u re th r a S p a rs e : S ta p h y lo c o c c i, c o r y n e b a c te ria . e n te ric s

V a g in a L a c tic a c id b a c te r ia d u rin g c h ild - b e a r in g y e a rs : o th e r w is e m ix e d

b a c te r ia 31

T h e L a n c e fie ld g r o u p in g s a r e b a s e d o n th e a n tig e n ic c h a r a c te r is tic s

o f a c e ll w a ll c a r b o h y d r a te c a lle d th e A s u b s ta n c e .
T h e m a in p a th o g e n ic g r o u p s fo r h u m a n s a r e A , B , C , D, a n d G .

• b o t h s t a te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • th e firs t s ta te m e n t is fa ls e , th e s e c o n d is tru e
T h e g e n u s S t r e p t o c o c c u s is a d iv e r s e c o lle c tio n o f g ra m -p o s itiv e c o c ci ty p ic a lly
a r r a n g e d in p a irs o r c h a in s . M o s t s p e c ie s a r e fa c u lta tiv e a n a e ro b e s . T h e ir n u tr itio n a l
r e q u ir e m e n ts a r e c o m p le x , n e c e s s it a tin g th e u s e o f b lo o d - o r s e r u m - e n r ic h e d m e d ia
fo r is o la tio n . C a r b o h y d r a t e s a r e fe r m e n t e d , r e s u ltin g in th e p r o d u c tio n o f la c tic a c id ,
a n d u n lik e s ta p h y lo c o c c a l s p e c ie s , s tr e p to c o c c i a r e c a ta la s e -n e g a tiv e .
D iffe re n t, o v e r la p p in g s c h e m e s a r e u s e d to c la s s if y s tr e p to c o c c i: (1 ) S e r o lo g ic
p r o p e r tie s : L an c efie ld g ro u p in g s ( o r ig in a lly A to W ) ; (2 ) H em o ly tic p attern s:
c o m p le t e ( b e t a [b ]) h e m o ly s is , in c o m p le te ( a lp h a [a ]) h e m o ly s is , a n d n o ( g a m m a [g ])
h e m o ly s is ; a n d (3 ) B io c h e m ic al ( p h y s io lo g ic ) p r o p e r tie s .
T h e L an c efie ld g ro u p in g s a r e b a s e d o n th e a n tig e n ic c h a r a c te r is t ic s o f a c e ll w a ll
c a r b o h y d r a te c a lle d th e C s u b s ta n c e . T h e m a in p a th o g e n ic g r o u p s fo r h u m a n s a r e A ,
B, C , D , a n d G , a n d e a c h g r o u p is g iv e n a s p e c ie s n a m e .
G ro u p A s tra in s a r e p a t h o g e n ic fo r h u m a n s . M o r e th a n 9 0 % o f s tr e p to c o c c a l d is e a s e
in h u m a n s is c a u s e d b y g r o u p A b e ta - h e m o ly tic s tr e p - S. pyogenes. T h e y a re fu r th e r
s u b d iv id e d b y A r a b ic n u m e r a ls in to s p e c if ic a n tig e n ic ty p e s b a s e d o n th e c e ll w a ll M
p ro tein . T h is M p r o te in s e e m s to b e c lo s e ly a s s o c ia te d w ith th e v ir u le n c e o f th e
b a c te r ia . O th e r im p o r ta n t c o m p o n e n ts in th e c e ll w a ll o f S . pyogenes in c lu d e
lip o te ic h o ic a c id a n d F p r o te in .
R em em b er: T o x in s p r o d u c e d b y G ro u p A b e ta - h e m o ly t ic s tr e p to c o c c i in c lu d e
s tr e p t o c o c c a l p y r o g e n ic e x o to x in s ( S p e ) A , B , C a n d F , D N a s e s A to D , s tr e p to ly s in s 0
a n d S , h y a lu r o n id a s e , a n d s tr e p to k in a s e A a n d B.
1 . S tre p to c o c c a l p y ro g e n ic e x o to x in A ( S p e A ) is a s u p e ra n tig e n ( a s is
S p e B ) p r o d u c e d b y Streptococcus pyogenes a n d is a s s o c ia te d w ith
s e v e r e in f e c t io n s c h a r a c te r iz e d b y r a s h , h y p o te n s io n , m u ltio r g a n fa ilu r e
a n d a h ig h m o rtality rate.
2 . O r a l S tr e p t o c o c c i a r e u s u a lly a lp h a -h e m o ly tic ( i.e ., S. viridans, S.
mutans, S. sanguis, a n d S. salivarius). T h e s e b a c te r ia a r e th e m o s t
c o m m o n o r g a n is m s c a u s in g s u b a c u te e n d o c a r d it is .
b a c te r ia 32

In th is g ra p h , a s ta n d a r d b a c te r ia l g r o w th c u r v e is d e p ic te d . W h ic h o f
th e fo llo w in g is tr u e o f th e s ta g e in d ic a te d b y "C "?

• m o r e lo g a r ith m ic b a c te r ia l g r o w th d u r in g C th a n d u r in g A
• m o r e lo g a r ith m ic b a c te r ia l g r o w th d u r in g C th a n d u r in g D
• le s s lo g a r ith m ic b a c te r ia l g r o w th d u r in g C th a n d u r in g A
• le s s lo g a r ith m ic b a c te r ia l g r o w th d u r in g C th a n d u r in g B

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • le s s lo g a r ith m ic b a c te r ia l g r o w th d u r in g C th a n d u r in g B
T h e b a c te r ia l g r o w th c u r v e r e fle c ts th e d y n a m ic s in a p o p u la tio n o f b a c te r ia
o v e r a p e r io d o f tim e .
W h e n b a c t e r ia a r e p la c e d in a fr e s h , n u t r ie n t - r ic h m e d iu m , t h e y e x h ib it fo u r
c h a r a c t e r is t ic p h a s e s o f p o p u la tio n g r o w th :
1. A = Lag phase
2. B = L o g ( lo g a r it h m ic o r e x p o n e n t ia l) p h a s e
3. C = M a x im u m s t a t io n a r y p h a s e
4. D = D e c lin e ( d e a th ) p h a s e
L a g p h a s e : c e lls a r e m e t a b o lic a lly a c tiv e b u t a r e n o t d iv id in g . T h is is a p e r io d
w h e n th e c e lls a r e r e s y n t h e s iz in g e n z y m e s , c o e n z y m e s , e tc ., n e c e s s a r y f o r
g r o w th a n d d iv is io n .
L o g p h a s e : b a c t e r ia a r e g r o w in g a n d d iv id in g a t a n e x p o n e n tia l, o r
lo g a r ith m ic , r a te . T h is is th e p e r io d o f f a s t e s t g r o w th ; th e g e n e r a t io n t im e is
m a x im a l a n d c o n s t a n t . N o te : M o s t c id a l a n t ib io t ic s w o r k b e s t d u r in g th is
p h a s e . T h is is th e b e s t p h a s e t o s t a in b a c t e r ia c u lt u r e t o s t u d y th e m .
M a x im u m s t a t io n a r y p h a s e : a t t h is p o in t, t h e m e d iu m is b e c o m in g d e p le t e d
in s o m e n u tr ie n ts , and t o x ic q u a n t it ie s o f w a s te m a t e r ia ls m ay be
a c c u m u la t in g . T h e n u m b e r o f n e w c e lls p r o d u c e d is o f f s e t b y th e n u m b e r o f
c e lls t h a t a r e d y in g ; th u s , th e t o ta l n u m b e r o f v ia b le c e lls r e m a in s c o n s ta n t.
D e a th p h a s e : c o n d it io n s a r e b e c o m in g le s s a n d le s s c o n d u c iv e to c e ll g r o w th .
C e lls a r e d y in g m o r e r a p id ly t h a n n e w o n e s a r e b e in g f o r m e d , r e s u lt in g in a
lo g a r it h m ic d e c r e a s e in th e n u m b e r o f c e lls .
b a c te r ia 33

E n d o to x in s a re p a r t o f th e o u te r m e m b r a n e o f th e c e ll w a ll o f:

• g r a m - p o s it iv e b a c te r ia o n ly
• g r a m - n e g a tiv e b a c te r ia o n ly
• b o th g r a m - p o s itiv e a n d g r a m - n e g a tiv e b a c te r ia
• n e ith e r g r a m - p o s itiv e n o r g r a m - n e g a tiv e b a c te r ia ; t h e y a r e a c o m p o n e n t o f
v ir u s e s

M IC R O B IO L O G Y /P A T H O L O G Y @ M e n ta ld e c l< S
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • g r a m - n e g a t iv e b a c te r ia o n ly
The b io lo g ic a l a c tiv ity of e n d o to x in is a s s o c ia t e d w it h th e
lip o p o ly s a c c h a r id e ( L P S ) . T o x ic it y is a s s o c ia te d w it h t h e lip id c o m p o n e n t
( L ip id A ) a n d im m u n o g e n ic it y is a s s o c ia t e d w it h th e p o ly s a c c h a r id e
c o m p o n e n ts . T h e c e ll w a ll a n t ig e n s (O a n tig e n s ) o f g r a m - n e g a t iv e b a c te r ia
a r e c o m p o n e n t s o f L P S . L P S e lic it s a v a r ie t y o f in f la m m a t o r y r e s p o n s e s . It
a c tiv a t e s c o m p le m e n t b y th e a lte r n a tiv e ( p r o p e r d in ) p a th w a y .

C h a r a c te r is tic s o f B a c te r ia l E n d o to x in s a n d E x n to x in s

P ro p e rty E n d o to x in E x o to x in

O rg a n is m s G r a in -n e g a tiv e G r a m - p o s itiv e a n d g r a m - n e g a tiv e

C h e m ic a l n a tu re L ip o p o ly s a c c h a rid e P ro te in

R e la tio n s h ip to c e ll P a rt o f o u te r m e m b ra n e E x tra c e llu la r, d iffu s ib le

D e n a tu r e d b y b o ilin g N o U s u a lly

A n tig e n ic Y es Y es

F o rm to x o id N o Y es

P o te n c y V e ry h ig h R e la tiv e ly h ig h

S p e c ific ity L o w d eg ree H ig h d e g r e e

E n z y m a tic a c tiv ity N o O f te n

P y ro g e n ic ity Y es O c c a s io n a lly

R e le a s e d b y o rg a n is m s N o Y es
b a c te r ia 34

W h ic h o f th e fo llo w in g is e s s e n tia l to th e fu n c tio n o f th e o u te r

m e m b r a n e o f g r a m -n e g a tiv e b a c te r ia ?

• p r o te in
• p a n tig e n r e c e p t o r s
• c o a g u la s e
• LPS

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • LPS
T h e fu n c tio n o f th e o u te r m e m b ra n e o f g ra m -n e g a tiv e b a c te ria is to a c t a s a protective
perm eability barrier. T h e o u te r m e m b ra n e is im perm eable to large m o le cu le s and h y d ro p h o b ic
c o m p o u n d s fro m th e e n viro n m e n t. LPS is e sse n tia l to th e fu n c tio n o f th e o u te r m e m b ra n e .
Important:
1. E n do to xins are not secreted by b a cte ria l ce lls. T h e b acte ria l cell m ust die a nd th e o u te r
m e m b ra n e be b ro ken d o w n fo r th e e n d o to xin to be re le a se d into th e b lo o d stre a m . T h e h ost's
re sp o n se s to e n d o to x in s in clu d e ch ills, fe ve r, w e a k n e s s , g e n e ra lize d a ch e s, a nd , in se ve re
c a se s, s h o c k a n d d e a th .
2. 2. E n d o to xin s a re highly potent lipopolysaccharides re lea se d fro m th e cell w a lls o f g ra m ­
n e g a tive b a cte ria . M in u te a m o u n ts in th e o ra l m u c o s a c a u s e inflam m ation and resorption
o f a d ja c e n t b o n e . E n d o to xin h a s a c h e m o ta c tic e ffe c t on neutrophilic granulocytes and
ind u ce s p h a g o c y to s is b y th e s e cells.
1. In a d d itio n to e nd oto xin, plaque bacteria a lso p ro du ce e n z y m e s (h ya lu ro n id a se ,
c o lla g e n a s e , c h o n d ro itin s u lfa ta s e , e la sta se , a n d p ro te a se s) th a t m a y in itia te
p e rio d o n ta l d ise a se . Free endotoxin is p re sen t in den tal plaque and in inflam ed
gingiva. Remember: T h e m o s t lik e ly so u rc e o f b a c te ria fo u n d in d ise a se d
p e rio d o n ta l tis s u e is subgingival plaque.
2. C ollagenase is th e p ro te a se w h ic h d e g ra d e s c o lla g e n , o n e o f th e b o d y's p rim a ry
c o n n e ctive tissu e s. In p a tie n ts w ith p e rio d o n ta l d ise a se , th e c o lla g e n w h ich fo rm s
th e s tru ctu ra l b a sis o f th e p e rio d o n tiu m is b ro ken dow n by co lla g e n a se . T his
p ro te a se has b e e n d e m o n s tra te d to be a p a rt o f th e c o m p o n e n t s y s te m in the
fo llo w in g b a cte ria : P o rp h y ro m o n a s s p e cie s, C los trid iu m s p e cie s, B a c te ro id e s
s p e cie s, a n d AA.
3. A lth o u g h m o s t b acte ria l e x o to x in s a re p ro te in a c e o u s in n a tu re , endotoxin is a
lip o p o ly s a c c h a rid e c o m p le x c o m p o s e d o f a lipid A (p o rtio n m o s t re s p o n s ib le fo r
to x ic a c tiv ity ) c o re polysaccharide, and an “O ” antig enic s id e chain.
4. Endotoxin ca n a ctiva te th e co m p le m e n t s yste m v ia th e a lte rn a tiv e p a th w ay. C 3
ca n b e a ctiva te d b y e n d o to x in in th e a b s e n c e o f p re c e d in g a ctiv a tio n o f C l , 4, and
2. A s a resu lt, th e v a rio u s c o m p le m e n t c o m p o n e n ts (C 3, 5 - 9 ) a re c o n s u m e d and
th e n th e ir a c tiv ity d is a p p e a rs o r is re d uce d fro m s e ru m .
b a c te r ia 35

D e te c tio n o f p ro te in A c a n b e u s e d a s a s p e c if ic id e n tif ic a tio n te s t fo r:

• Streptococcus pyrogenes
• Neisseria gonorrhoeae
• Salmonella
• Staphylococcus aureus

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • Staphylococcus aureus
S. aureus a re p y o g e n ic g ra m - p o s itiv e c o c c i th a t fo r m c lu s te r s lik e b u n c h e s o f g ra p e s .
T h e s e b a c te ria c a u s e a m y ria d o f s k in le s io n s (b o ils , c a rb u n c le s , im p e tig o , a n d s c a ld e d -
s k in s y n d r o m e ) a s w e ll a s a b s c e s s e s , s e p s is , o s te o m y e litis , p n e u m o n ia , e n d o c a rd itis , fo o d
p o is o n in g , a n d to x ic s h o c k s y n d r o m e (T S S ). S. aureus is a m a jo r c a u s e o f h o s p ita l-
a c q u ire d (n o s o c o m ia l) in fe c tio n o f s u rg ic a l w o u n d s a n d in fe c tio n s a s s o c ia te d w ith in
d w e llin g m e d ic a l d e v ic e s . S. aureus c a u s e s fo o d p o is o n in g b y r e le a s in g e ntero toxins in to
fo o d , a n d to x ic s h o c k s y n d r o m e b y re le a s e o f s u p e ra n tig e n s in to th e b lo o d s tre a m .
T h e s u rfa c e o f m o s t S. aureus s tr a in s ( b u t n o t th e c o a g u la s e - n e g a tiv e s ta p h y lo c o c c i) is
c o a te d w ith pro tein A. T h is p ro te in is b o u n d to e ith e r th e p e p tid o g ly c a n la y e r o r th e
c y to p la s m ic m e m b r a n e a n d h a s a u n iq u e a ffin ity fo r b in d in g to th e F c r e c e p to r o f Ig G a n d
in h ib itin g c o m p le m e n t fix a tio n .
T h e g e n u s N eisseria c o n ta in s tw o im p o r ta n t h u m a n p a th o g e n s , N. gonorrhoeae a n d N.
meningitidis. N. gonorrhoeae c a u s e s g o n o r rh e a , a n d N. meningitidis c a u s e s
m e n in g o c o c c a l m e n in g itis . N. gonorrhoeae in fe c tio n s h a v e a h ig h p re v a le n c e a n d lo w
m o rta lity , w h e re a s N. meningitidis in fe c tio n s h a v e a lo w p re v a le n c e a n d h ig h m o rta lity .
Salmonella is a g ra m - n e g a tiv e fa c u lta tiv e r o d -s h a p e d b a c te riu m in th e s a m e
p ro te o b a c te r ia l fa m ily a s Escherichia coli, th e fa m ily E n te ro b a c te ria c e a e , tr iv ia lly k n o w n as
"enteric" b a c te ria . In h u m a n s , Salmonella is th e c a u s e o f tw o d is e a s e s c a lle d
salm o n ello sis: e n te ric fe v e r (ty p h o id ), r e s u ltin g fr o m b a c te ria l in v a s io n o f th e
b lo o d s tre a m , a n d acu te g astro en teritis, r e s u ltin g fro m a fo o d b o rn e in fe c tio n /in to x ic a tio n .
1 . S trep to cocci a re a e ro b ic to fa c u lta tiv e ly a n a e r o b ic g ra m - p o s itiv e c o c c i th a t
g r o w in p a irs o r c h a in s in c u ltu r e . T h e y a re th e m o s t n u m e r o u s g ro u p o f
m ic r o o r g a n is m s th a t o c c u r in th e o ra l c a v ity , w h e re th e y c a n g ro w a n d c a u s e
d ental caries ( m a in ly S. mutans). O th e r m o re s e rio u s in fe c tio n s c a u s e d b y
S tre p to c o c c u s in c lu d e p n e u m o n ia (S. pneumoniae), rh e u m a tic fe v e r (S .
pyogenes), a n d h e a rt v a lv e in fe c tio n s (S. viridans).
2. S ta p h ylokinase ( p r o d u c e d b y S. aureus), S trep to kinase ( p r o d u c e d b y
h e m o ly tic s tr e p to c o c c i), a n d U ro kinase a re e n z y m e s th a t cleave
p lasm ino g en , p r o d u c in g p la s m in , w h ic h c a u s e s th e liq u e fa c tio n o f fib rin .
T h e y a re u s e d c lin ic a lly in th e r e m o v a l o f b lo o d c lo ts .
b a c te r ia 36

E a c h o f th e fo llo w in g b a c te r ia p r o d u c e h y a lu r o n id a s e E X C E P T o n e .
W h ic h o n e is th e E X C E P T IO N ?

• Staphylococcus aureus
• Streptococcus pyogenes
• Bordetella pertussis
• Clostridium perfringens

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • Bordetella pertussis
E x tr a c e llu la r B a c te ria l P r o te in s T h a t A r e C o n s id e r e d In v a s in s

I n v a s in B a c te ria In v o lv e d A c tiv ity

Ilyaluronidase Streptococci, staphylococci and closiridia Degrades hyaluronic acid o f connective tissue

Collagenase Clostridium species Dissolves collagen framework o f muscles

Neuraminidase Vibrio cholcrae and Shigella dysenteriac D egrades neuram inic acid o f intestinal mucosa

Coagulasc Staphylococcus aureus Coverts fibrinogen to fibrin which causes clotting

Kinases Staphylococci and streptococci Converts plasm inogen to plasm in w hich digests fibrin

Lcukocidin Staphylococcus aureus Disrupts neutrophil membranes and causes discharge o f

lysosomal granules

Streptolysin S treptococcus pyogenes Capable o f lysing erythrocytes, leukocytes, and platelets

Hemolysins Streptococci, staphylococci, and Clostridia Phospholipases or lecithinases that destroy red blood
cells (and other cells) by lysis

Lecithinases Clostridium perfringens Destroy lecithin in cell membranes

Phospholipases C lostridium perfringens Destroy phospholipids in cell membrane

Anthrax EF Bacillus anthracis One com ponent (EF) is an adenylate cyclase which
causes increased levels o f intracellular cyclic AMP

Pertussis AC Bordetella pertussis One toxin com ponent is an adenylate cyclase that acts
locally producing an increase in intracellular cyclic
AMP
b a c te r ia 37

M y c o b a c te r iu m s p e c ie s , a lo n g w ith m e m b e r s o f a re la te d g e n u s
N o c a r d ia , a r e c la s s if ie d as :

• c o a g u la s e - p o s it iv e b a c te r ia
• c o lla g e n a s e - p o s it iv e b a c te r ia
• a c id - fa s t b a c t e r ia
• p h o s p h o lip a s e - p o s it iv e b a c te r ia

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • a c id -fa s t b acteria
Mycobacterium tuberculosis is n o t c la s s ifie d as e ith e r g ra m - p o s itiv e o r g r a m ­
n e g a tiv e b e c a u s e it d o es n ot h a v e th e c h e m ic a l c h a r a c te r is tic s o f e ith e r, a lth o u g h
th e b a c te r ia do co n tain p e p tid o g ly c a n ( m u r e in ) in th e ir c e ll w a ll.
Im p o rta n t: Mycobacterium tuberculosisis a fa ir ly la rg e n o n - m o tile r o d - s h a p e d , a c id -
fa s t, n ia c in - p r o d u c in g b a c te r iu m . It p r o d u c e s n e ith e r e x o to x in s o r e n d o to x in s . M a n y
n o n - p a th o g e n ic m y c o b a c te r ia a re p a r t o f th e n o r m a l flo r a o f h u m a n s , fo u n d m o s t
o fte n in d ry a n d o ily lo c a le s . Mycobacterium tuberculosis is a n o b lig a te ae ro b e. F o r
th is re a s o n , in th e c la s s ic c a s e o f tu b e r c u lo s is , th e M . T B c o m p le x e s a re a lw a y s
fo u n d in th e w e ll-a e r a te d u p p e r lo b e s o f th e lu n g s . T h e b a c te r iu m is a fa c u lta tiv e
in tr a c e llu la r p a r a s ite , u s u a lly o f m acro p h ag es, a n d h a s a s lo w g e n e ra tio n tim e of
1 5 - 2 0 h o u rs , a p h y s io lo g ic a l c h a r a c te r is tic th a t m a y c o n tr ib u te to its v ir u le n c e .
1. A c id -fa s t s ta in in g is o n e o f th e m e th o d s u s e d to d ia g n o s e a c tiv e
tu b e r c u lo s is . It is a m e th o d o f s ta in in g u s e d in b a c te r io lo g y in w h ic h a
s m e a r o n a s lid e is flo o d e d w ith c a r b o l- fu c h s in s ta in , d e c o lo r iz e d w ith
a c id a lc o h o l, a n d c o u n te r s ta in e d w ith m e th y le n e b lu e . A c id - fa s t
o r g a n is m s r e s is t d e c o lo r iz a tio n a n d a p p e a r re d a g a in s t a b lu e
b a c k g r o u n d w h e n v ie w e d u n d e r a m ic r o s c o p e . T h is p r o p e r ty o f b e in g
a c id - fa s t is a ttrib u ta b le to th e p r e s e n c e o f lip id s a n d w a x e s (m y c o lic
a c id s ) in th e c e ll w a ll o f c e r ta in b a c te ria .
2. T h e c la s s ic skin te s t (P P D s k in te s t) is a n o th e r m e th o d o f te s tin g fo r
tu b e r c u lo s is . It m a y in d ic a te a n in fe c tio n , b u t n o t w h e th e r th e in fe c tio n is
a c tiv e . A p u r ifie d p ro te in d e r iv a tiv e (P P D ) e x tr a c t fro m mycobacterium
tuberculosis is in je c te d s u b c u ta n e o u s ly , a n d th e a r e a n e a r th e in je c tio n is
o b s e r v e d fo r e v id e n c e o f a d e la y e d h y p e rs e n s itiv ity rea c tio n . A
p o s itiv e te s t in d ic a te s a h y p e r s e n s itiv ity to tu b e r c u lo - p r o te in s .
3. C o m m o n a c id -fa s t b a c te ria o f m e d ic a l im p o r ta n c e in c lu d e th e
Mycobacterium tuberculosis, Mycobacterium leprae, and Mycobacterium
avium c o m p le x ( M A C ) w h ic h c o n s is ts o f tw o s p e c ie s - M. avium and M.
intracellulare.
b a c te r ia 38

In a d d itio n to p e p tid o g ly c a n , th e a c id -fa s t c e ll w a ll o f M y c o b a c te r iu m

c o n ta in s a la rg e a m o u n t o f g ly c o lip id s , e s p e c ia l ly _______ th a t m a k e
u p a p p r o x im a te ly 6 0 % o f th e a c id -fa s t c e ll w a ll.

• b e ta - la c ta m a s e s
• lip o p o ly s a c c h a r id e s
• t e ic h o ic a c id s
• m y c o lic a c id s

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • m y c o lic a c id s
M y c o b a c te r ia h a v e a p e p tid o g ly c a n la y e r ( s lig h tly d iff e r e n t s tr u c tu r e ) , w h ic h is
in te r tw in e d w ith a n d c o v a le n tly a t ta c h e d to a n a r a b in o g a la c ta n p o ly m e r a n d
s u r r o u n d e d b y a w a x lik e lip id c o a t o f m y c o lic a c id ( la r g e a - b r a n c h e d b - h y d r o x y
f a tt y a c id s ) , c o r d f a c t o r ( g ly c o lip id o f t r e h a lo s e a n d tw o m y c o lic a c id s ) , w a x D
( g ly c o lip id o f 1 5 to 2 0 m y c o lic a c id s a n d s u g a r ) , a n d s u lfo lip id s . T h e c o a t is
r e s p o n s ib le f o r v ir u le n c e a n d is a n tip h a g o c y tic .

F u n c tio n s o f th e A c id -F a s t C e ll W a ll C o m p o n e n ts :
1 . T h e p e p tid o g ly c a n p r e v e n ts o s m o tic ly s is .
2 . T h e m y c o lic a c id s a n d o th e r g ly c o lip id s a ls o im p e d e th e e n tr y o f
c h e m ic a ls c a u s in g th e o r g a n is m s to g r o w s lo w ly a n d b e m o r e r e s is ta n t to
c h e m ic a l a g e n ts a n d ly s o s o m a l c o m p o n e n ts o f p h a g o c y te s th a n m o s t
b a c te r ia .
3 . T h e s u r fa c e p r o te in s in th e a c id - fa s t c e ll w a ll, d e p e n d in g o n th e s tr a in
a n d s p e c ie s , c a r r y o u t a v a r ie ty o f a c tiv it ie s , in c lu d in g :
» F u n c t io n in g a s e n z y m e s
° S e r v in g a s a d h e s in s . A d h e s in s e n a b le th e b a c te r iu m to a d h e r e in t im a t e ly
to h o s t c e lls a n d o th e r s u r fa c e s in o r d e r to c o lo n iz e a n d r e s is t flu s h in g .
4 . T h e p e r ip la s m c o n ta in s e n z y m e s fo r n u tr ie n t b r e a k d o w n a s w e ll a s
p e r ip la s m ic b in d in g p r o te in s to fa c ilita te th e t r a n s f e r o f n u tr ie n ts a c r o s s th e
c y to p la s m ic m e m b r a n e .
_ 1. Is o n ia z id in h ib its m y c o lic a c id b io s y n th e s is a n d is a n e ff ic ie n t
a n tim y c o b a c te r ia l a g e n t.
2 . A tu b e r c le o r G h o n fo c u s is a s m a ll, r o u n d e d n o d u le p r o d u c e d b y
in fe c tio n w ith M . tu b e r c u lo s is . It is th e p r im a r y lu n g le s io n o f
p u lm o n a r y T B . R a n k e c o m p le x is th e r e s u lt o f g h o n fo c u s th a t h a s
h e a le d , fib r o s e d , a n d is s o m e tim e s c a lc ifie d .
b a c te r ia 39

A m a jo r fa c to r in th e c a r io g e n ic ity o f S . m u ta n s is th e a b ilit y to a d h e r e
to th e to o th s u r fa c e . T h is a tta c h m e n t is a c h ie v e d la r g e ly in p a r t d u e to
th e p r e s e n c e o f a n e x t r a c e llu la r g ly c o c a ly x , or:

• p la s m a m e m b r a n e
• c a p s u le
• p e llic le
• r e tic u lu m

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • c a p s u le
T h e c a p s u le is a g e la t in o u s c o a t w h ic h s u r r o u n d s th e c e ll w a ll o f c e r ta in
b a c t e r ia a n d is e s p e c ia lly im p o r t a n t in p r o te c tin g th e s e c e lls a g a in s t
p h a g o c y to s is b y e u k a r y o t ic c e lls . T h e p r e s e n c e o f a c a p s u le c a n b e a m a jo r
f a c t o r in d e t e r m in in g t h e p a t h o g e n ic it y o f a b a c te r iu m ; t h a t is , th e a b ilit y o f a
b a c te r iu m t o c a u s e d is e a s e in t h e o r g a n is m t h a t it in fe c ts . O t h e r im p o r t a n t
f u n c t io n s in c lu d e m e d ia t e a d h e r e n c e o f c e lls t o s u r fa c e s ( i.e ., c a r ie s o n th e
to o th s u r fa c e s ) a n d f o r id e n tific a tio n p u r p o s e s . W h e n t h e p o ly s a c c h a r id e
c a p s u le s a r e t r e a t e d w ith a n tis e r u m , t h e y s w e ll, a llo w in g t h e m to b e id e n t if ie d .
T h e s e a n tip h a g o c y t ic p o ly s a c c h a r id e c a p s u le s s u r r o u n d in g t h e c e lls o f
s tr a in s o f streptococcus pneumoniae, f o r e x a m p le , p e r m it t h e s e b a c te r ia to
e v a d e th e n o r m a l d e f e n s e m e c h a n is m s o f t h e h o s t, a llo w in g t h e m to
r e p r o d u c e a n d c a u s e t h e s y m p t o m s o f p n e u m o n ia . T h e v ir u le n c e o f o t h e r
b a c te r ia , in c lu d in g Haemophilus influenzae, Klebsiella pneumoniae, a n d
Cryptococcus neoformans is a ls o e n h a n c e d b y c a p s u le p r o d u c tio n .
1. T h e p la s m a m e m b r a n e ( c e ll m e m b r a n e , c y t o p la s m ic m e m b r a n e )
is m a d e o f tw o la y e r s o f p h o s p h o lip id s . T h e m e m b r a n e h a s m a n y
p r o t e in s ( 7 0 % o f t h e m a s s o f t h e m e m b r a n e ) e m b e d d e d in it. T h e
m a jo r f u n c t io n s in c lu d e : ( 1 ) s e le c t iv e p e r m e a b ilit y a n d t r a n s p o r t o f
s o lu te s ; (2 ) e le c tr o n t r a n s p o r t a n d o x id a t iv e p h o s p h o r y la tio n , in
a e r o b ic s p e c ie s ; (3 ) e x c r e tio n o f h y d r o ly t ic e x o e n z y m e s ; (4 ) b e a r in g
th e e n z y m e s a n d c a r r ie r m o le c u le t h a t fu n c t io n in t h e b io s y n t h e s is
o f D N A , c e ll w a ll p o ly m e r s , a n d m e m b r a n e lip id s ; a n d (5 ) b e a r in g
th e r e c e p to r s a n d o t h e r p r o te in s o f t h e c h e m o t a c t ic a n d o t h e r
s e n s o r y t r a n s d u c t io n s y s te m s .
2 . T h e c e ll w a ll is th e m e m b r a n e o f t h e c e ll t h a t f o r m s e x te r n a l to t h e
p la s m a m e m b r a n e w h o s e m a in r o le is t o g iv e c e lls r ig id ity , s tr e n g th
a n d p r o te c tio n a g a in s t m e c h a n ic a l s tr e s s . In a d d it io n to g iv in g
o s m o t ic p r o te c tio n , th e c e ll w a ll p la y s a n e s s e n tia l r o le in c e ll
d iv is io n , a s w e ll a s s e r v in g a s a p r im e r f o r its o w n b io s y n th e s is .
b a c te r ia 40

W h ic h o f th e fo llo w in g a r e a s s o c ia te d w it h a G r a m -n e g a tiv e c e ll w a ll?

S e le c t a ll th a t a p p ly .

• t h ic k m u r e in la y e r
• lip o p o ly s a c c h a r id e la y e r s
• t e ic h o ic a c id s
• m y c o lic a c id s
• t h in m u r e in la y e r

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • lip o p o ly s a c c h a r id e la y e r s
• th in m u re in la y e r

G ra m -p o s it iv e c e ll w a ll:
• T h ic k ( 1 5 - 8 0 n a n o m e te r s )
• T h ic k m u r e in la y e r t h a t m a k e s u p a p p r o x i m a t e l y 9 0 % o f t h e c e ll w a ll
• T e ic h o lc a cid s, p o ly s a c c h a r id e s t h a t s e r v e a s a t t a c h m e n t s it e s f o r
b a c t e r io p h a g e s

G r a m - n e g a tiv e c ell w a ll:

• T h i n ( 1 0 n a n o m e te r s )
• M o r e c o m p le x ( m u l ti la y e r e d ) t h a n g r a m - p o s it iv e c e ll w a ll
• T h in m u r e in la y e r t h a t a c c o u n ts f o r o n l y a b o u t 1 0 % o f t h e c e ll w a ll
• L ip o p r o te in s a r e a n in te g r a l p a r t o f t h e c e ll w a ll
• L i p o p o l y s a c c h a r id e la y e r s (LP S o r e n d o to x i n )
• P h o s p h o lip id s
• P r o te in s _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _

* * * T h e p r o te in s , lip o p o ly s a c c h a rid e la y e rs , a n d p h o s p h o lip id s m a k e u p th e cell

e n v e lo p e o f th e g ra m -n e g a tiv e b a c te r ia l c e ll. T h is o u te r m e m b r a n e p r o te c ts th e c e ll
fro m a n tib io tic s ( e .g ., p e n ic illin ) a n d e n z y m e s (e .g ., ly s o z y m e ) .
[|| b a ck gr "| < B a c te ria l m u re in is a u n iq u e ty p e o f p e p tid o g ly c a n . P e p tid o g ly c a n is a
“w p o ly m e r o f s u g a r s (a g ly c a n ) c r o s s - lin k e d b y s h o r t c h a in s o f a m in o a c id s
( p e p tid e ) . A ll b a c te r ia l p e p tid o g ly c a n s c o n ta in N - a c e ty lm u ra m ic a c id ,
w h ic h is th e d e fin itiv e c o m p o n e n t o f m u re in .
2. T h e c e ll w a lls o f a rc h a e a m a y b e c o m p o s e d o f p ro te in , p o jy s a c c h a rid e s ,
o r p e p tid o g ly c a n -lik e m o le c u le s , b u t n ev e r d o th e y c o n ta in m u re in . T h is
fe a tu r e d is tin g u is h e s th e a r c h a e b a c te r ia fr o m o th e r b a c te r ia .
b a c te r ia 41

M o s t s p e c ie s o f la c tic a c id b a c te r ia fe r m e n t g lu c o s e in to g a la c to s e .
L a c to b a c illu s s p e c ie s a r e f r e q u e n tly fo u n d in a s s o c ia tio n w ith d e n ta l
c a rie s .

• b o th s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e fir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n t a ld e c l« S
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • t h e fir s t s t a te m e n t is fa ls e , t h e s e c o n d is tr u e
M o s t s p e c ie s o f la c tic a c id b a c t e r ia fe r m e n t g lu c o s e in to la c ta te , h e n c e th e
n a m e Lactobacillus. T h e m o s t c o m m o n a p p lic a t io n o f Lactobacillus is
in d u s tr ia l, s p e c if ic a lly f o r d a ir y p r o d u c tio n . T h is g e n u s a ls o c o n t a in s s e v e r a l
b a c t e r ia th a t m a k e u p p a r t o f th e n a tu r a l f lo r a o f th e h u m a n v a g in a . B e c a u s e o f
t h e ir a b ility t o d e r iv e la c tic a c id fr o m g lu c o s e , t h e s e b a c t e r ia c r e a t e a n a c id ic
e n v ir o n m e n t w h ic h in h ib its g r o w th o f m a n y b a c te r ia l s p e c ie s w h ic h c a n le a d to
u r o g e n ita l in fe c tio n s .
A lt h o u g h Lactobacillus s p e c ie s a r e n o r m a lly p r e s e n t in lo w n u m b e r s in th e
o r a l c a v ity , t h e y a r e f r e q u e n t ly fo u n d in a s s o c ia tio n w ith d e n ta l c a r ie s
( e s p e c ia lly Lactobacillus casei), m ost p r o b a b ly as s e c o n d a ry m ic r o b ia l
in v a d e r s .
Lactobacillus acidophilus is a d d e d to c o m m e r c ia l m ilk p ro d u c ts to a s s is t
la c t o s e in t o le r a n t in d iv id u a ls in d ig e s t in g la c to s e s u g a r s . T h e e n z y m e s
p r o d u c e d b y t h e s e b a c t e r ia c o n v e r t m ilk s u g a r s t o p r o d u c t s t h a t d o n o t c a u s e
G l p r o b le m s .
L a c tic a c id b a c te r ia in c lu d e Lactobacillus a n d Streptococcus. T h e s e
b a c t e r ia u s e th e la c tic a c id f e r m e n t a t io n p a t h w a y in w h ic h p y r u v a t e is r e d u c e d
to la c tic a c id . T h e s e t w o b a c te r ia a r e a ls o r e fe r r e d to a s a c id u r ic , m e a n in g
t h a t t h e y c a n t o le r a t e a n a c id e n v ir o n m e n t , a n d a c id o g e n ic , m e a n in g a c id
f o r m in g .
1. Lactobacillus is g e n e r a lly h a r m le s s to h u m a n s , r a r e ly in c itin g
h a r m fu l in fe c tio n s o r d is e a s e s . T r e a t m e n t o f t h is v a n c o m y c in -
r e s is t a n t m ic r o b e u s u a lly c o n s is t s o f h ig h d o s e s o f p e n ic illin in
c o m b in a t io n w it h g e n t a m ic in .
2. Streptococcus mutans is t h e m a in c u lp r it in d e n ta l c a r ie s
( e s p e c ia lly s m o o th s u r fa c e c a r ie s ) .
3. Actinom yces h a s b e e n fo u n d to b e a c a u s a t iv e a g e n t o f r o o t
s u r fa c e c a r ie s .
b a c te ria 42

T h e tw o o r g a n is m s m o s t c o m m o n ly a s s o c ia te d w ith th e e tio lo g y o f
lo c a liz e d a g g r e s s iv e p e r io d o n tit is a r e C a p n o c y to p h a g a o c h ra ce u s
and:

• a c tin o b a c illu s a c t in o m y c e te m c o m ita n s (a a )

• w o lin e lla r e c ta
• p o r p h y r o m o n a s g in g iv a lis
• a c tin o m y c e s is r a e lii

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I - V o lu m e 1 3 - © 2 0 1 7
 • a c t in o b a c illu s a c tin o m y c e t e m c o m it a n s (a a )
Im p o r ta n t: T h e n e w c la s s if ic a t io n s y s te m f o r p e r io d o n t it is is m o r e
d e s c r ip t iv e a n d n o t a s t e m p o r a l a s w a s th e p r e v io u s s y s te m . T h e t e r m s a d u lt,
ju v e n ile , e a r ly o n s e t, a n d p r e p u b e r ta l h a v e b e e n r e p la c e d w it h v a r io u s fo r m s
o f c h r o n ic a n d a g g r e s s iv e d is e a s e . T h e te r m r e fr a c to r y p e r io d o n t it is h a s b e e n
r e m o v e d a s a d is t in c t d is e a s e e n tity , a s th e c u r r e n t t h in k in g is t h a t a n y t y p e o f
p e r io d o n titis m a y b e r e fr a c to r y .
A q q r e s s iv e p e r io d o n titis ( fo r m e r ly c a lle d J u v e n ile p e r io d o n titis ) o c c u rs in
t w o fo r m s :
1. G e n e r a liz e d fo r m ( fo r m e r ly k n o w n a s r a p id ly p r o g r e s s iv e p e r io d o n titis ) :
P r e v o t e lla in t e r m e d ia a n d E ik e n e lla c o r r o d e n s p r e d o m in a t e . It o c c u r s
b e tw e e n th e a g e s o f 1 2 - 2 5 a n d is c h a r a c t e r iz e d b y ra p id , s e v e r e
p e r io d o n ta l d e s tr u c tio n a ro u n d m ost te e th . It is c h a r a c t e r iz e d by
e p is o d ic , r a p id , a n d s e v e r e a t t a c h m e n t lo s s .
2 . L o c a liz e d fo rm : G r a m - n e g a t iv e a n a e ro b e s A c tin o b a c illu s
a c t in o m y c e t e m c o m it a n s (A a ) and C a p n o c y to p h a g a s p e c ie s
( o c h r a c e u s ) p r e d o m in a te . P r e v o t e lla in t e r m e d ia a n d E ik e n e lla c o r r o d e n s
m a y a ls o b e p r e s e n t t o a le s s e r e x te n t . It o c c u r s in a n o t h e r w is e h e a lt h y
a d o le s c e n t ( 1 2 - 1 9 ) . It is c h a r a c t e r iz e d b y r a p id a n d s e v e r e a tta c h m e n t
lo s s c o n f in e d to t h e in c is o r s a n d f ir s t m o la r s . T h e o n e o u ts ta n d in g
n e g a tiv e fe a t u r e is th e r e la tiv e a b s e n c e o f lo c a l f a c t o r s ( p la q u e ) t o e x p la in
th e s e v e r e p e r io d o n ta l d e s t r u c t io n w h ic h is p r e s e n t. P o s s ib le e tio lo g ic
f a c t o r s in c lu d e a g e n e t ic p r e d is p o s it io n o r a d y s fu n c tio n o f n e tr o p h ils (a
c h e m o t a c t ic d e fe c t) .
N o te : A a a n d C a p n o c y t o p h a g a s p e c ie s ( s p e c if ic a lly C. ochraceus) a r e a ls o
a s s o c ia t e d w it h p e r io d o n t it is in ju v e n ile d ia b e te s .
b a c te r ia 43

S tre p to c o c c u s m u tan s g r o w s o p tim a lly a t a p H w e ll b e lo w 7 .0 . F ro m

th is s ta te m e n t, it c a n b e r e a s o n e d th a t S tre p to c o c c u s m u ta n s is:

• a c id o p h ilic
• a c id o g e n ic
• a c id u r ic
• a lk a lip h ilic
• n e u tr o p h ilic

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • a c id o p h ilic
T h e r a n g e o f p H o v e r w h ic h a n o r g a n is m g r o w s is d e fin e d b y t h r e e c a r d in a l
p o in ts : t h e m in im u m p H , b e lo w w h ic h th e o r g a n is m c a n n o t g r o w , th e
m a x im u m p H , a b o v e w h ic h t h e o r g a n is m c a n n o t g r o w , a n d t h e o p tim u m p H ,
a t w h ic h th e o r g a n is m g r o w s b e s t.
T h o s e w h ic h g r o w b e s t a t n e u tr a l p H ( 7 .0 ) a re c a lle d n e u tr o p h ils . M ost
b a c te r ia a r e c o n s id e r e d to b e n e u tr o p h ils .
E x a m p le s in c lu d e : Pseudomonas aeruginosa, Clostridium sporogenes,
and Proteus s p e c ie s .
Those w h ic h g ro w at an o p tim a l p H w e ll b e lo w n e u tr a lity ( 7 .0 ) a re c a lle d
a c id o p h ile s .
E x a m p le s in c lu d e : Thiobacillus thiooxidans, Sulfolobus acidocaldarius,
and Bacillus acidocaldarius.
N o te : O b lig a t e a c id o p h ile s , s u c h a s s o m e Thiobacillus s p e c ie s , a c tu a lly
r e q u ir e a lo w p H f o r g r o w th s in c e t h e ir m e m b r a n e s d is s o lv e a n d t h e c e lls ly s e
a t n e u tr a lity .
T h o s e t h a t g r o w b e s t u n d e r a lk a lin e c o n d it io n s a r e c a lle d a lk a lip h ile s .
E x a m p le s in c lu d e : Nitrobacter s p e c ie s a n d Streptococcus pneumoniae.
R e m e m b e r : A c id u r ic m e a n s t h a t th e b a c te r ia is c a p a b le o f o r c a n t o le r a te
liv in g u n d e r a c id c o n d it io n s . A c id o g e n ic m e a n s t h a t th e b a c t e r ia c a n p r o d u c e
r e la tiv e ly h ig h c o n c e n t r a t io n s o f a c id (Streptococcus a n d Lactobacillus
p r o d u c e la c tic a c id a s t h e p r im a r y f e r m e n t a t io n p r o d u c t) . S tr e p to c o c c i a r e th e
p r im a r y a c id o g e n ic m ic r o o r g a n is m s in t h e o r a l c a v ity .
Im p o r ta n t: L a c tic a c id is t h e m a in c a u s e o f e n a m e l d e c a lc if ic a tio n .
b a c te r ia 44

W h ic h o f th e fo llo w in g s ta te m e n ts is N O T tr u e r e g a r d in g E s c h e ric h ia
c o li ( £ . coli) s p e c ie s ?

• th e y a r e c a ta la s e - n e g a tiv e
• th e y f e r m e n t la c to s e
• t h e y f e r m e n t g lu c o s e
• th e y r e d u c e n itr a te s to n itr ite s
• th e y a r e o x id a s e - n e g a tiv e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • th e y a r e c a ta la s e - n e g a t iv e
Escherichia coli (E. coii) is a g r a m -n e g a tiv e fa c u lt a t iv e a n a e r o b ic ro d th a t
b e lo n g s to th e E n t e r o b a c te r ia c e a e . T h e m a jo r it y o f E. c o li a re
f a m ily
h a r m le s s c o m m e n s a ls o f th e in te s tin e , b u t a f e w is o la te s h a v e b e c o m e
p a t h o g e n ic b y a c q u ir in g v ir u le n c e g e n e s e n c o d e d o n p la s m id s o r in
b a c t e r io p h a g e D N A . D is e a s e s c a u s e d b y E. coli in c lu d e d ia r r h e a , u r in a r y tr a c t
in fe c tio n , b a c te r e m ia , a n d m e n in g itis .
C h a r a c te r is tic fe a t u r e s o f E. c o li s p e c ie s :
• C a ta la s e - p o s itiv e
• O x id a s e - n e g a tiv e
• F e r m e n t g lu c o s e a n d la c to s e
• R e d u c e n it r a t e s t o n itr ite s
• P o s it iv e r e a c tio n w it h m e th y l r e d
• P o s s e s s s p e c ia liz e d v ir u le n c e fa c to r s , i. e . , a d h e s in s a n d e x o to x in s
S ix m o s t c o m m o n ly e n c o u n te r e d p a th o ty p e s of E. c o li t h a t a re
d ia r r h e o g e n ic :
• E n te r o to x ig e n ic ( E T E C )
• E n te r o in v a s iv e ( E I E C )
• E n t e r o h e m o r r h a g ic ( E H E C )
• E n t e r o p a t h o g e n ic ( E P E C )
• E n t e r o a g g r e g a t iv e ( E A E C )
• D iff u s e ly a d h e r e n t ( D A E C )
O t h e r p a t h o t y p e s in c lu d e s t r a in s t h a t e x p r e s s S h ig a - lik e t o x in s . S u c h s tr a in s
a r e c a lle d a s s h ig a t o x ig e n ic E . coli ( S T E C ) .
b a c te r ia 45

W h ic h o f th e fo llo w in g te s ts is th e k e y c r it e r io n fo r th e id e n tif ic a tio n

o f S ta p h y lo c o c c u s a u re u s ?

• c a ta la s e te s t
• c o a g u la s e t e s t
• in d o le te s t
• b ile s o lu b ility t e s t

M IC R O B IO L O G Y /P A T H O L O G Y I^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • coag u lase test
A p o sitive coag u lase tes t is an im p o r ta n t c r ite r io n fo r th e iden tificatio n of
S ta p hylococcus aureus.
S. aureus p ro d u c e s coag u lase enzym e th a t c lo ts p la s m a o r a g g lu tin a te s th e o rg a n is m s .
C o a g u la s e b in d s to a s e ru m fa c to r fo rm in g a c o m p le x th a t c o n v e rts fib r in o g e n to fib rin ,
le a d in g to c lo t fo rm a tio n . T h is c o a g u la s e te s t is a n im p o r ta n t c r ite r io n to d iffe r e n tia te S.
aureus fr o m m o s t o f th e o th e r s p e c ie s o f s ta p h y lo c o c c i o r fro m n o n -s ta p h y lo c o c c i s p e c ie s ,
w h ic h a re c o a g u la s e - n e g a tiv e .
C o ag u lase en zym e in S. aureus strain s exists in tw o form s:
1. C ell-b o u n d : T h is fo rm o f c o a g u la s e is b o u n d to th e c e ll w a ll o f s ta p h y lo c o c c u s a n d is
c a lle d a c lu m p in g fa c to r. It c o n v e rts fib r in o g e n to in s o lu b le fib rin th a t c a u s e s th e
c lu m p in g o f s ta p h y lo c o c c i. It is d e te c te d w ith th e slid e c oag u lase test.
° T h e slid e c oag u lase test is p e r fo r m e d o n a g la s s s lid e b y m ix in g a d e n s e
e m u ls io n o f th e o rg a n is m w ith p la s m a . C lu m p in g o c c u r s w ith in 3 0 s e c o n d s if th e
o rg a n is m is S. aureus a n d th e te s t is s a id to b e p o s itiv e .
2. Cell-free: T h is fo rm o f c o a g u la s e is n o t b o u n d to th e c e ll w a ll. It r e a c ts w ith th e
g lo b u lin p la s m a fa c to r (a c o a g u la s e - re a c tin g fa c to r) to fo rm a th ro m b in - lik e fa c to r
c a lle d s ta p h y lo th r o m b in , w h ic h a c ts a s a c a ta ly s t in c o n v e rtin g fib r in o g e n to in s o lu b le
fib rin . It is d e te c te d w ith th e h e lp o f th e tub e c oag u lase test (a m o re d e fin itiv e te s t).
" T h e tub e coag u lase tes t is p e r fo r m e d in a tu b e c o n ta in in g p la s m a w ith th e
c o lo n ie s o f th e o rg a n is m to b e d e te c te d . T h e tu b e is in c u b a te d a t 35°C fo r 4 h o u rs
a n d th e n e x a m in e d . If a c lo t is fo rm e d , th e te s t is p o s itiv e fo r S. aureus. If n o c lo t is
fo rm e d , th e tu b e c a n b e r e in c u b a te d a t ro o m te m p e r a tu r e fo r re - e x a m in a tio n a fte r
24 h o u rs . E x a m in a tio n a t 4 h o u rs is n e c e s s a r y to e x c lu d e fa ls e n e g a tiv e s , w h ic h
m a y o c c u r a fte r 24 h o u rs w ith s tr a in s o f S. aureus th a t p ro d u c e fib r in o ly s in .

Note:
Bile s olub ility test: D iffe re n tia te s Streptococcus pneumoniae, w h ic h a re b ile s o lu b le , fro m
o th e r s tr e p to c o c c i s p e c ie s .
C atalase test: D e te r m in e s m a jo r g ro u p s o f g ra m - p o s itiv e c o c c i; fo r e x a m p le , s ta p h y lo c o c c i
th a t a re c a ta la s e - p o s itiv e a n d s tr e p to c o c c i a n d e n te ro c o c c i th a t a re c a ta la s e - n e g a tiv e .
Indole test: F o r p re s u m p tiv e d e te c tio n o f E. coli in u rin e s p e c im e n s .
b a c te ria 46

W h ic h o n e o f th e fo llo w in g is N O T c o r r e c t re g a r d in g th e p h a g o c y to s is
o f b a c te ria ?

• n e u tr o p h ils + m a c r o p h a g e + m o n o c y te s —> p h a g o c y tic c e lls

• b a c t e r ia + v a c u o le - * p h a g o s o m e
• p h a g o s o m e + ly s o s o m e s —►p h a g o ly s o s o m e
• b a c t e r ia + p h a g o c y tic c e ll —* p in o c y to s is

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • b a c te r ia + p h a g o c y tic c e ll p in o c y to s is
P h a g o c y to s is is th e p ro c e s s by w h ic h la r g e p a r t ic le s such as
m ic r o o r g a n is m s , c e ll d e b r is , a n d f o r e ig n a n t ig e n s a r e in g e s te d a n d d e s t r o y e d
b y p h a g o c y te s , i.e ., n e u tr o p h ils , m o n o c y te s , a n d m a c r o p h a g e s , w h e r e a s
p in o c y to s is is t h e in g e s t io n o f m in u t e p a r tic le s s u c h a s e x t r a c e llu la r f lu id a n d
p a r t ic u la t e c o n s t it u e n t s in t o t h e c e ll c y to p la s m .
T h e s te p s in v o lv e d in p h a g o c y to s is a r e a s fo llo w s :
1. S u b s ta n c e s , in c lu d in g b a c te r ia t h a t n e e d t o b e e lim in a t e d a r e u s u a lly
c o a t e d w it h o p s o n in ( a n tib o d y o r c o m p le m e n t ) t h a t b in d s t o t h e c e ll s u r f a c e
r e c e p to r s o n th e p h a g o c y t e s a n d d r a g s b a c t e r ia a lo n g w it h it.
2 . B in d in g t r ig g e r s o u t w a r d e v a g in a t io n o f t h e p la s m a m e m b r a n e , i.e ., th e
e d g e s o f th e p la s m a m e m b r a n e o f t h e p h a g o c y t e a r o u n d th e p o in t o f
a t t a c h m e n t o f b a c t e r ia f o r m p s e u d o p o d ia t h a t e n v e lo p t h e b a c te r ia .
3 . T h e b a c te r ia a r e e n g u lf e d a n d e n c lo s e d in a v a c u o le w ith in t h e c y to p la s m
c a lle d a p h a g o s o m e .
4 . T h e p h a g o s o m e is p u s h e d t o t h e in te r io r o f t h e c e ll w it h t h e a id o f a c tin a n d
o t h e r c o n t r a c t ile f ib r ils in t h e c y t o p la s m t h a t s u r r o u n d t h e p h a g o s o m e .
5 . F u s io n of th e phagosom e w it h a ly s o s o m e o c c u rs to fo r m a
p h a g o ly s o s o m e ( o r s e c o n d a r y ly s o s o m e ) . T h e e n z y m e s w ith in th e
ly s o s o m e d e s t r o y t h e d e a d b a c t e r ia a n d t h e ir p r o d u c ts .
6 . T h e r e s id u a l b a c te r ia l d e g r a d a tio n p r o d u c t is e it h e r e x p e lle d fr o m t h e c e ll
b y e x o c y to s is o r th e r e is fo r m a tio n o f a r e s id u a l b o d y in t h e c y t o p la s m t h a t
c o n ta in s in d ig e s tib le m a te r ia l, w h ic h is a ls o e v e n t u a lly e x c r e te d b y t h e c e ll.
b a c te r ia 47

W h ic h o f th e fo llo w in g is th e p ro c e s s in w h ic h D N A is tr a n s fe r r e d
fr o m a b a c te ria l d o n o r c e ll to a r e c ip ie n t c e ll b y c e ll-to -c e ll c o n ta c t?

• tr a n s la tio n
• tr a n s d u c t io n
• tr a n s c r ip tio n
• c o n ju g a tio n

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • c o n ju g a tio n
C o n ju g a tio n is a fo r m o f s e x u a l r e p r o d u c tio n in w h ic h D N A is tr a n s f e r r e d fr o m
o n e liv e b a c te r iu m to a n o t h e r th r o u g h d ir e c t c o n ta c t. T h is p h y s ic a l c o n t a c t is
e s t a b lis h e d th r o u g h t h e p r e s e n c e o f p ili.
• T h e a b ilit y t o t r a n s f e r D N A b y c o n ju g a t io n is d e p e n d e n t o n th e p r e s e n c e o f
a c y t o p la s m ic e n tity te r m e d t h e fe r t ilit y fa c to r , o r F.
• C e lls c a r r y in g F a r e te r m e d F+; c e lls w ith o u t F a r e F \ F is a s m a ll, c ir c u la r
D N A e le m e n t t h a t a c ts lik e a m in ic h r o m o s o m e . It is a n e x a m p le o f a c la s s
o f e le m e n ts te r m e d p la s m id s , w h ic h a r e s e lf - r e p lic a t in g e x tr a c h r o m o s o m a l
D N A m o le c u le s .
_ 1. In c o n ju g a t io n , th e g r e a te s t a m o u n t o f g e n e tic in fo r m a tio n is
tr a n s f e r r e d fr o m o n e c e ll to a n o t h e r ( c o m p a r e d to t r a n s d u c t io n a n d
tr a n s fo r m a tio n ) .
2 . C o n ju g a t io n o c c u r s m o r e f r e q u e n t ly t h a n t r a n s f o r m a t io n ; it ta k e s
p la c e w ith in m e m b e r s o f d if f e r e n t g e n e r a ( e .g ., E s c h e r ic h ia -
S h ig e lla , S a lm o n e lla - S e r r a tia ) .
3 . C a n r e s u lt in p a s s a g e o f g e n e s f o r a n tib io tic r e s is ta n c e fr o m o n e
b a c te r iu m to a n o th e r ; b a c te r iu m p o te n tia l f o r p a t h o g e n ic it y c a n
in c r e a s e .
4 . F fa c to r s a r e p la s m id s tr a n s f e r r e d fr o m a d o n o r c e ll ( a n F + c e ll) to a
r e c ip ie n t c e ll ( a n P c e ll) d u r in g c o n ju g a tio n .
5 . A n H fr ( h ig h fr e q u e n c y o f r e c o m b in a t io n ) is a c e ll w ith a n F p la s m id
in c o r p o r a t e d in t o th e c h r o m o s o m e .
6 . D u r in g c o n ju g a t io n , p o r tio n s o f t h e H fr c h r o m o s o m e a r e
tr a n s f e r r e d fr o m t h e H fr b a c te r iu m to t h e F 'b a c t e r iu m .
7 . T r a n s fe r o f D N A w ith in b a c te r ia l c e ll o c c u r s v ia tr a n s p o s o n s ,
w h ic h a r e p o r tio n s o f D N A t h a t m o v e fr o m o n e s ite o n th e
c h r o m o s o m e t o a n o t h e r ( o r t o a p la s m id ) .
b a c te r ia 48

T h e io d in e u s e d in G ra m s ta in in g o f b a c te r ia a c ts a s a

• c a ta ly s t
• m o rd a n t
• c h e la to r
• d e c o lo r iz e r

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • m o rd a n t

G ram s ta in in g reag en ts:

C ry s ta l v io le t, io d in e s o lu tio n (a m o r d a n t th a t fo rm s a c r y s ta l v io le t- io d in e
c o m p le x w ith th e r ib o n u c le a r p ro te in in th e c e ll), a c e to n e -a lc o h o l (a lip id s o lv e n t
th a t a c ts a s a d e c o lo r iz e r ) , safran in (a s e c o n d a ry s ta in ) , a n d w ater.
G ra m s ta in in g tec h n iq u e:
• P la c e th e s p e c im e n o n a c le a n m ic r o s c o p e s lid e a n d le t it a ir d ry .
• F ix th e s p e c im e n u s in g h e a t b y g e n tly p a s s in g o v e r a fla m e .
• C o v e r th e s p e c im e n w ith th e c r y s ta l v io le t s ta in fo r 1 m in u te .
• R in s e w ith w a te r . D o n o t b lo t.
• C o u n te r s ta in w ith G r a m io d in e (a m o r d a n t) fo r 1 m in u te th a t fo r m s a c r y s ta l v io le t
- io d in e c o m p le x .
• R in s e w ith w a te r. D o n o t b lo t.
• D e c o lo r iz e w ith g e n tle a g ita tio n in 3 0 % a c e to n e - a lc o h o l fo r 3 0 s e c o n d s .
• R in s e w ith w a te r. D o n o t b lo t.
• C o v e r th e s m e a r w ith th e re d d y e , s a fr a n in , fo r 10 to 2 0 s e c o n d s .
• R in s e w ith w a te r a n d a ir d ry .
G ra m s ta in in g is a d iffe re n tia l s ta in in g te c h n iq u e th a t w o r k s o n th e p r in c ip le th a t
cells stain d iffe re n tly a c c o rd in g to th e ir p ro p ertie s , su ch as th e cell w ajl
stru cture. B a c te r ia c a n b e d iv id e d in to tw o b ro a d g ro u p s d e p e n d in g o n th e ir
reactio n to G ra m stain:
• G ra m -p o s itiv e b a c teria re ta in th e p u rp le c o lo r o f th e c ry s ta l v io le t-io d in e
c o m p le x e v e n w h e n e x p o s e d to th e lip id s o lv e n t ( a c e to n e - a lc o h o l) . T h is a b ility is
d u e to th e p r e s e n c e o f a th ic k la y e r o f p e p tid o g ly c a n in th e ir c e ll w a ll a n d no
o u te r m em b ran e.
• G ra m -n e g a tiv e b a c teria lo s e th e p u rp le c o lo r o f th e c r y s ta l v io le t - io d in e
c o m p le x w h e n e x p o s e d to a lip id s o lv e n t ( a c e to n e - a lc o h o l) a s th e y h a v e a thin
p e p tid o g ly c a n w a ll a n d a n o u te r lip id -c o n ta in in g m e m b ra n e . G r a m - n e g a tiv e
b a c te r ia th u s b e c o m e c o lo r le s s a n d stain p in k w h e n e x p o s e d to a c o u n te r s ta in ,
s a fra n in .
b a c te r ia 49

T h e a tta c h m e n t o f m ic r o b e s a n d o th e r fo r e ig n c e lls to p h a g o c y te s by
a n tib o d y m o le c u le s s u c h a s Ig G a n d c o m p le m e n t p r o te in s s u c h a s
C 3 b is c a lle d :

• c o n ju g a tio n
• tr a n s fo r m a tio n
• o p s o n iz a tio n
• a d h e s io n

M 1C R O B IO L O G Y /P A T H O L O G Y U H J e n t a ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • o p s o n iz a tio n
O p s o n iz a t io n , o r e n h a n c e d a tta c h m e n t, r e fe r s t o t h e a n t ib o d y m o le c u le s Ig G
( o r Ig M ) a n d t h e c o m p le m e n t p r o t e in s C 3 b a n d C 4 b a t t a c h in g a n t ig e n s to
p h a g o c y te s . T h is r e s u lts in m u c h m o r e e f f ic ie n t p h a g o c y to s is .
T h e p r o c e s s s t a r t s w ith Ig G ( o r Ig M ) b e in g m a d e a g a in s t a s u r fa c e a n t ig e n o f
th e o r g a n is m o r c e ll to b e p h a g o c y to s e d . T h e F a b p o r tio n o f Ig G r e a c ts w ith
e p it o p e s o f t h e a n tig e n . T h e F c p o r tio n o f Ig G c a n t h e n b in d t o n e u t r o p h ils a n d
m a c r o p h a g e s t h u s s t ic k in g t h e a n t ig e n to t h e p h a g o c y te . B in d in g o f Ig G t o th e
F c r e c e p t o r a ls o a c t iv a t e s t h e p h a g o c y te .
A t t a c h m e n t t h e n p r o m o t e s d e s t r u c t io n o f t h e a n tig e n . M ic r o o r g a n is m s a r e
p la c e d in p h a g o s o m e s w h e r e t h e y a r e u ltim a te ly d ig e s t e d b y ly s o s o m e s . If th e
a n tig e n is a c e ll t o o la r g e t o b e in g e s te d , s u c h a s v ir u s - in f e c t e d h o s t c e lls ,
t r a n s p la n t c e lls , a n d c a n c e r c e lls , t h e p h a g o c y t e e m p t ie s t h e c o n t e n t s o f its
ly s o s o m e s d ir e c tly o n to th e c e ll f o r e x t r a c e llu la r k illin g .
O p s o n iz a t io n is e s p e c ia lly im p o r t a n t a g a in s t m ic r o o r g a n is m s w it h
a n t ip h a g o c y t ic s t r u c t u r e s s u c h a s c a p s u le s s in c e o p s o n iz in g a n t ib o d ie s m a d e
a g a in s t t h e c a p s u le a r e a b le to s t ic k c a p s u le s t o p h a g o c y te s . In v a c c in e s
a g a in s t p n e u m o c o c c a l p n e u m o n ia a n d H a e m o p h ilu s in f lu e n z a e ty p e , it is th e
c a p s u la r p o ly s a c c h a r id e t h a t is g iv e n a s t h e a n t ig e n in o r d e r t o s t im u la t e th e
b o d y to m a k e o p s o n iz in g a n ti b o d ie s a g a in s t t h e e n c a p s u la t e d b a c te r iu m .
Im p o r ta n t: T h e tw o m a jo r o p s o n in s a r e Ig G a n d C 3 b .
b a c te r ia 50

A ll o f th e fo llo w in g s ta te m e n ts re g a r d in g M y c o p la s m a o r g a n is m s a re
tr u e E X C E P T fo r o n e . W h ic h o n e is th e E X C E P T IO N ?

• th e y a r e th e s m a lle s t b a c te r ia
• th e y a r e d e v o id o f a c e ll w a ll
• th e y a r e s u r r o u n d e d o n ly b y a c e ll m e m b r a n e
• th e y la c k s t e r o ls in t h e ir c y to p la s m ic m e m b r a n e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • th e y la c k s te ro ls in th e ir c y to p la s m ic m e m b ran e
M y c o p la s m a s a re s h o rt ro d s th a t b e lo n g to th e c la s s M o llic u te s . T h e y a re th e s m a lle st
b a c te r ia l c e lls , m e a s u r in g 0.2 pm . T h e y h a v e o n ly a cell m e m b ra n e a n d la c k a cell
w all. T h u s , m y c o p la s m a s a re n o t a ffe c te d b y a n tim ic r o b ia ls , s u c h a s (3-lactam s
(p e n ic illin s a n d c e p h a lo s p o r in s ) , th a t in h ib it c e ll w a ll b io s y n th e s is . U n lik e e u k a r y o te s ,
p r o k a r y o te s la c k s te ro l in th e ir c y to p la s m ic m e m b ra n e . M y c o p la s m a s a re th e o n ly
p ro k a ry o te s th a t c o n ta in s te ro ls in th e ir c y to p la s m ic m em b ran e.
M y c o p la s m a s u b g ro u p s a n d in fe c tio n s th e y c au se

M yc o p las m a D is e a s e s /ln fe c tio n s

Is o la tio n site
s u b g ro u p
U p p e r r e s p ira to ry in fe c tio n ,
M. pneumoniae R e s p ira to ry tra c t
p n e u m o n ia
C e rv ic itis , v a g in itis , a n d m a y b e
G e n ito u r in a r y tra c t p r o s ta titis
C o n ju n c tiv a e o f n e o n a te s
C o n ju n c tiv itis
M. hominis B lo o d
P e rip a rtu m s e p s is
S u r g ic a l w o u n d s
S te r n o to m y in fe c tio n
J o in ts
A r th r itis

M. orale O ro p h a ry n x N ot know n
M a y b e a s s o c ia te d w ith p e r io d o n ta l
M. salivarium O ro p h a ry n x , g in g iv a
d is e a s e
G e n ito u r in a r y tra c t, b lo o d , M u ltis y s te m d is e a s e in H IV /A ID S
M. fermentans
tis s u e s
U re th ritis , c e rv ic itis , p e lv ic
M. genitalium G e n ito u rin a ry tra c t
in fla m m a to r y d is e a s e
U re th ritis , u p p e r g e n ito u rin a r y
Ureaplasma spp. G e n ito u rin a ry tra c t
in fe c tio n
b a c te r ia 51

S p ir o c h e te s a r e a p r in c ip a l e tio lo g ic f a c to r in n e c r o tiz in g u lc e r a tiv e

g in g iv itis .
P r e v o te lla in te r m e d ia is th e m o s t c o m m o n s p ir o c h e te fo u n d in
p a tie n ts w ith th is d is e a s e .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ® M e n ta ld e c lc s
P art I • V o lum e 13 • © 20 1 7
 • th e firs t s ta te m e n t is tru e , th e s e c o n d is fa ls e
A N U G is a n a c u te r e c u r rin g g in g iv a l in fe c tio n o f c o m p le x e tio lo g y , c h a r a c te r iz e d b y
n e c r o s is o f p a p illa e , s p o n ta n e o u s b le e d in g a n d p a in . T h e tw o p rin c ip a l b ac teria
a s s o c ia te d w ith A N U G a re P re v o te lla in te rm e d ia a n d S p iro ch e te s ( Treponema
denticola is th e in te r m e d ia te -s iz e d s p ir o c h e te a s s o c ia te d w ith A N U G ).
Fusobacterium s p e c ie s a s w e ll a s Selenomonas s p e c ie s c a n a ls o b e s e e n .
Im p o rta n t: A c c o r d in g to th e A m e r ic a n A s s o c ia tio n o f P e r io d o n tic s (A A P ) , A N U G is
n o w c o r r e c tly r e fe r e n c e d s im p ly a s “N e c ro tiz in g U lc e ra tiv e G in g iv itis ” w ith o u t th e
“ a c u te ” q u a lifie r . N o te : T h e N a tio n a l B o a r d s m a y o r m a y n o t r e fle c t th is c h a n g e .
N U G ( fo r m e r ly c a lle d " V in c e n t's in fe c tio n " o r " tr e n c h m o u th " ) is a c o n d itio n w h ic h
p r e s e n ts r a th e r p a th o g n o m o n ic s ig n s a n d s y m p to m s .
• In te r p r o x im a l g in g iv a l n e c r o s is (“ p u n c h e d - o u t” • F e to r o r is
p a p illa e )
• M a r g in a l g in g iv a l p s e u d o m e m b r a n e fo r m a tio n • G in g iv a b le e d s e a s ily
• P a in • M e ta llic ta s te
• L o w -g r a d e fe v e r
• N o a tta c h m e n t lo s s ly m p h a d e n o p a th y

1. P r e d o m in a n t s u b g in g iv a l b a c te r ia a s s o c ia te d w ith g in g iv a l h e a lth :
° Streptococcus mitis a n d sanguis
° Actinomyces viscosus a n d naeslundii
° Rothia dentocariosus
° Staphylococcus epidermidis
» S m a ll s p ir o c h e te s
2. Ig G is th e im m u n o g lo b u lin th a t is fo u n d in th e h ig h e s t c o n c e n tratio n in
s e r u m s a m p le s fr o m p a tie n ts w ith p e rio d o n ta l d is e a s e .
b a c te r ia 52

C e lls fr o m p la n ts , fu n g i, a n d a n im a ls a r e p ro k a r y o te s , w h e r e a s
b a c te r ia a n d a r c h a e a b e lo n g to th e e u k a r y o te s .
T h e b a c te r ia l 7 0 S r ib o s o m e is m a d e u p o f 5 0 S a n d 3 0 S s u b u n it s a n d
is a m a jo r ta r g e t fo r a n tib a c te r ia l d ru g s .

• b o t h s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e firs t s ta te m e n t is fa ls e , th e s e c o n d is tru e
O n th e b a s is o f c e llu la r c h a r a c te r is tic s , a ll liv in g c e lls a re c la s s ifie d a s p r o k a r y o te s o r
e u k a ry o te s . P ro k a ry o te s a re th e p rim itiv e u n ic e llu la r o rg a n is m s , su ch as
b acteria, a rc h ae a , an d b lu e-green alg ae. P r o k a r y o tic c e lls la c k n u clei lin e d w ith
n u c le a r m e m b r a n e ; in s te a d , th e ir D N A is lo o s e ly o r g a n iz e d in th e c e ll c y to p la s m .
U n lik e p r o k a r y o te s , e u k a ryo te s a re u s u a lly m u lti- c e llu la r o r g a n is m s , a n d c o n ta in a
n u c le u s a n d o th e r o r g a n e lle s e n c a p s u la te d w ith in m e m b r a n e s . P lan ts, a n im a ls,
p ro toz oa, an d fu n g i a re e u karyo tes .
D is tin g u is h in g fe a tu re s o f e u k a ry o te s a n d p ro k a ryo te s :

Features P ro k a ry o tic cell E u k a ry o tic cell

S ize 0 .5 - 3 p m >5 pm

N u c le a r e n v e lo p e a b s e n t N u c le u s e n v e lo p e d
N u c leu s D N A in s in g le , c lo s e d lo o p S tr a n d s o f D N A , d ip lo id
c h ro m o s o m e genom e

O r g a n e lle s lik e
m ito c h o n d r ia , G o lg i
O rg an elle s N o o r g a n e lle s
b o d ie s , e n d o p la s m ic
r e tic u lu m a re p r e s e n t

N o m ito s is in r e p r o d u c tio n , M ito s is a n d m e io s is in

R e p ro d u ctio n r e p r o d u c tio n
r e p lic a te b y b in a r y fis s io n

R ib o s o m e s a re th e c e ll’s m a c h in e r y to m a k e p r o te in s . T h e r e la tiv e ly s m a ll 7 0 S
b a c te r ia l r ib o s o m e , c o n s is tin g o f 3 0 S a n d 5 0 S s u b u n its , d iffe r s fro m th e 8 0 S
r ib o s o m e o f e u k a r y o te s m a k in g it a m a jo r ta r g e t fo r a n tib a c te ria l d ru g s , i.e .,
te trac y c lin e , m a c ro lid es , a n d a m in o g ly c o s id e s .
T e tr a c y c lin e in h ib its b a c te ria l p ro tein s y n th e s is b y b in d in g r e v e r s ib ly to th e 3 0 S
b a c te r ia l r ib o s o m e u n it. A m in o g ly c o s id e s a n d m a c ro lid e s c a r r y o u t th e in h ib itio n b y
b in d in g d ir e c tly a n d ir r e v e r s ib ly to 3 0 S a n d 5 0 S s u b u n its , re s p e c tiv e ly .
b a c te r ia 53

In te r m s o f e x tr a c tin g c h e m ic a l e n e r g y , a e r o b ic r e s p ir a tio n is m o r e
e ffic ie n t th a n fe r m e n ta tio n B E C A U S E a e r o b ic r e s p ir a tio n u tiliz e s
m e ta b o lic a lly d e r iv e d o r g a n ic a c id s a s te r m in a l e le c tr o n r e c e p to r s .

• b o th th e s t a te m e n t a n d th e r e a s o n a r e c o r r e c t a n d r e la te d
• b o th th e s t a te m e n t a n d th e r e a s o n a r e c o r r e c t b u t N O T r e la te d
• th e s ta te m e n t is c o r r e c t, b u t th e r e a s o n is N O T
• th e s ta te m e n t is N O T c o r r e c t, b u t th e r e a s o n is c o r r e c t

• N E IT H E R th e s t a te m e n t N O R th e r e a s o n is c o r r e c t

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • th e s ta te m e n t is c o rrec t, b u t th e reaso n is N O T
R e s p iratio n r e fe r s to th e m e th o d o f o b ta in in g m e ta b o lic e n e r g y th a t in v o lv e s an
o x id a tiv e p h o s p h o ry la tio n . It in v o lv e s th e fo rm a tio n o f A T P d u r in g e le c tr o n
tr a n s fe r . It c a n b e a e ro b ic ( w ith m o le c u la r o x y g e n a s th e te rm in a l e le c tr o n a c c e p to r )
o r a n a e ro b ic (w ith n itr a te o r s u lfa te a s th e te r m in a l e le c tr o n a c c e p to r ) . R e s p ira tio n is
m u ch m o re e ffic ie n t th a n fe rm e n ta tio n , th u s r e s p irin g o r g a n is m s , in c lu d in g us,
h a v e c o m e to d o m in a te th e e a rth . F e r m e n tin g o r g a n is m s a r e r e s tr ic te d to n ic h e s
w h e r e o x y g e n is la c k in g a n d s u ita b le c a r b o n s o u r c e s e x is t.
A ero b ic re s p iratio n in v o lv e s a c e ll m e m b r a n e r e s p ir a to r y (e le c tro n tran s p o rt)
c h a in . T h e e le c tr o n tr a n s p o r t c h a in is p r e s e n t in th e in n e r m ito c h o n d ria l
m e m b ra n e a n d is th e fin a l c o m m o n p a th w a y b y w h ic h e le c tr o n s d e r iv e d fro m
d iffe r e n t fu e ls o f th e b o d y flo w to o x y g e n . It h a s fo u r s ta g e s :
1. G ly c o ly s is 3. T h e c itr ic a c id c y c le
4. E lectro n tra n s p o rt ch ain a n d
2. F o r m a tio n o f a c e ty l c o e n z y m e A
c h e m io s m o s is
F e rm e n ta tio n is d e fin e d a s a n e n e r g y y ie ld in g p r o c e s s w h e re b y o rg an ic
m o le c u le s s e r v e a s b o th e le c tr o n d o n o r s a n d e le c tr o n a c c e p to r s . T h e m o le c u le
b e in g m e ta b o liz e d d o e s n o t h a v e a ll its p o te n tia l e n e rg y e x tr a c te d fr o m it. In o th e r
w o r d s , it is n o t c o m p le te ly o x id iz e d .
K ey p o in ts of fe rm e n ta tio n :
• N A D + is a lm o s t a lw a y s re d u c e d to N A D H • O x y g e n is n o t in v o lv e d
• F e r m e n ta tio n r e s u lts in a n e x c e s s o f N A D H • E n e r g y y ie ld s a r e lo w
• P y r u v a te is o fte n a n im p o r ta n t in te r m e d ia te
• E n e r g y is d e r iv e d fr o m S u b strate -L ev e l
P h o s p h o ry la tio n
F e r m e n ta tio n c a n in v o lv e a n y m o le c u le th a t c a n u n d e r g o o x id a tio n . T y p ic a l
s u b s tr a te s in c lu d e s u g a r s (s u c h a s g lu c o s e ) a n d a m in o a c id s . T y p ic a l p r o d u c ts
d e p e n d u p o n th e s u b s tr a te b u t c a n in c lu d e o r g a n ic a c id s ( la c tic a c id , a c e tic a c id ),
a lc o h o ls ( e th a n o l, m e th a n o l, b u ta n o l), k e to n e s ( a c e to n e ) a n d g a s e s (H 2 a n d C 0 2).
N A D H is re c y c le d b a c k to N A D + th ro u g h fe r m e n ta tio n s o th e p r o c e s s d o e s n 't g r in d to
a h a lt.
b a c te r ia 54

T h e b a c te r ia m o s t s tr o n g ly lin k e d w ith lo c a liz e d a g g r e s s iv e

p e r io d o n tit is (fo r m e r ly c a lle d lo c a liz e d ju v e n ile p e r io d o n titis ) is:

• Porphyromonas gingivalis
• Tannerella forsythia
• Actinobacillus actinomycetemcomitans
• Prevotella intermedia

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • A ctinobacillus actinom ycetem com itans
In th e h e a lth y m o u th , m o r e th a n 3 5 0 s p e c ie s o f m ic r o o r g a n is m s h a v e b e e n
fo u n d . P e r io d o n ta l in fe c t io n s a r e lin k e d to fe w e r th a n 5 % o f th e s e s p e c ie s .
• P e rio d o n ta l h e a lth is c h a r a c te r iz e d b y th e p r e s e n c e o f th e fo llo w in g
b a c te r ia : G r a m - p o s it iv e b a c te r ia such as Streptococcus sanguis,
Streptococcus mitis, Actinomyces viscosus, Actinomyces naeslundii a n d a
fe w g r a m - n e g a tiv e s p e c ie s s u c h a s Veilloneila parvula a n d Capnocytophaga
ochracea.
• In p e r io d o n ta l d is e a s e , th e b a c te r ia l b a la n c e s h ift s o v e r t o g r a m -n e g a tiv e ,
m o tile , s tr ic tly a n a e r o b ic b a c te r ia . In fla m m a to r y d is e a s e a n d in ju r y c a n n o t
d e v e lo p w ith o u t th e s e b a c te r ia .
A m o n g th e b a c te r ia m o s t im p lic a te d in p e r io d o n ta l d is e a s e a n d b o n e lo s s a r e
th e fo llo w in g :
• A ctinobacillus actinom ycetem com itans ( A a ) : a s s o c ia te d w it h a g g r e s s iv e
p e r io d o n ta l d is e a s e ( fo r m e r ly c a lle d e a r ly o n s e t p e r io d o n tit is ) a n d lo c a liz e d
a g g r e s s iv e p e r io d o n tit is ( fo r m e r ly c a lle d lo c a liz e d ju v e n ile p e r io d o n titis ) .
• Porphyrom onas gingivalis: a s s o c ia te d w ith c h r o n ic a n d a g g re s s iv e
p e r io d o n titis .
• Tannerella forsythia ( fo r m e r ly Bacteroides forsythus): s tr o n g ly lin k e d to
p e r io d o n ta l d is e a s e .
• Treponem a denticola, s o k r a n s k ii: a s s o c ia te d w ith deep p e r io d o n t a l
p o c k e ts c h r o n ic p e r io d o n titis a n d A N U G .
• Prevotella interm edia: a s s o c ia te d w ith d e e p p e r io d o n ta l p o c k e t s , c h r o n ic
p e r io d o n tit is a n d A N U G .
N o te : A ll d e n ta l p la q u e - in d u c e d p e r io d o n ta l d is e a s e s a re m ix e d in fe c tio n s .
N o n e o f th e m is c a u s e d b y a s in g le p a t h o g e n .
N o te :Eikenella corrodens, Campylobacter rectus, Fusobacterium nucleatum,
Peptostreptococcus, Prevotella nigrescens, E n te r ic r o d s / Pseudomonas s p e c ie s
a n d Eubacterium s p e c ie s h a v e a ls o b e e n im p lic a t e d a s p e r io d o n ta l p a th o g e n s .
b a c te r ia 55

A n a e r o b ic b a c te r ia p r o d u c e s u p e r o x id e d is m u ta s e a n d c a ta la s e
enzym es.
M o s t b a c te r ia g r o w in e ith e r th e p r e s e n c e o r th e a b s e n c e o f o x y g e n .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
• t h e fir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • t h e fir s t s ta te m e n t is fa ls e , t h e s e c o n d is tr u e
O b lig a te a e r o b e s r e q u ir e 0 2 f o r g r o w th ; t h e y u s e 0 2 a s a fin a l e le c tr o n
a c c e p t o r in a e r o b ic r e s p ir a tio n . A e r o b ic b a c te r ia p r o d u c e s u p e r o x id e
d is m u t a s e a n d c a ta la s e e n z y m e s w h ic h c a n d e t o x if y h y d r o g e n p e r o x id e a n d
s u p e r o x id e r a d ic a ls t h a t a r e t h e t o x ic b y p r o d u c t s o f a e r o b ic m e ta b o lis m .
M o s t b a c te r ia g r o w in t h e p r e s e n c e o r t h e a b s e n c e o f o x y g e n . T h e s e b a c te r ia
a r e r e f e r r e d to a s f a c u lt a t iv e a n a e r o b e s . T h e s e o r g a n is m s c a n s w it c h
b e tw e e n a e r o b ic a n d a n a e r o b ic ty p e s o f m e ta b o lis m . U n d e r a n a e r o b ic
c o n d it io n s ( n o 0 2) t h e y g r o w b y fe r m e n t a t io n o r a n a e r o b ic r e s p ir a tio n , b u t in
t h e p r e s e n c e o f 0 2 t h e y s w it c h to a e r o b ic r e s p ir a tio n .
O b lig a te a n a e r o b e s ( o c c a s io n a lly c a lle d a e r o p h o b e s ) d o n o t n e e d o r u s e
0 2 a s a n u tr ie n t. In fa c t, 0 2 is a t o x ic s u b s ta n c e , w h ic h e it h e r k ills o r in h ib it s
t h e ir g r o w th .
A e r o to le r a n t a n a e ro b e s a re b a c te r ia w ith an e x c lu s iv e ly a n a e r o b ic
( fe r m e n ta tiv e ) ty p e o f m e ta b o lis m b u t th e y a r e in s e n s itiv e t o t h e p r e s e n c e o f
0 2. T h e y liv e b y f e r m e n t a t io n a lo n e w h e t h e r o r n o t 0 2 is p r e s e n t in th e ir
e n v ir o n m e n t.
B a c te r ia t h a t c a n r e ly e n tir e ly o n in o r g a n ic c h e m ic a ls f o r t h e ir e n e r g y a n d
s o u r c e o f c a r b o n ( C 0 2) a r e r e fe r r e d to a s a u to tr o p h s ( lith o tr o p h s ) , w h e r e a s
m a n y b a c t e r ia a n d a n im a l c e lls t h a t r e q u ir e o r g a n ic c a r b o n s o u r c e s a r e k n o w n
a s h e te r o tr o p h s ( o r g a n o tr o p h s ) .
 T e r m s u s e d to d e s c r i b e o x y g e n 'c l a t i o n s in M i c r o o r g a n i s m s

E n v iro n m en t
G roup A erob ic A n aerob ic O xygen effect
O b l i g a t e a e r o b e G r o w t h N o g r o w t h R e q u i r e d

O b l i g a t e a n a e r o b e N o g r o w t h G r o w t h T o x i c

F a c u l t a t i v e a n a e r o b e G r o w t h G r o w t h N o t r e q u i r e d b u t

u t i l i z e d w h e n

a v a i l a b l e

A e r o t o l e r a n t a n a e r o b e G r o w t h G r o w t h N o t r e q u i r e d a n d

n o t u t i l i z e d

D is tr ib u tio n s o f s u p e r o x id e d is m u ta s e , c a t a la s e a n d
p e r o x i d a s e in p r o k a r y o t e s w i t h d i f f e r e n t o x y g e n t o l e r a n c e s
G rou p S u p e r o x id e C a t a la s e P e r o x id a s e
d is m u ta s e
O b lig a te a ero b es an d m o st + + -
fa cu lta tiv e an aerob es (e .g .. E n terics)
M o s t aerotoleran t an aerob es + - +
(e .g .. S tr ep to co c ci)
O b lig a te an aerob es - - -
( e .g ., C lostrid ia, B a c tero id es)
b a c te r ia 56

S o m e g r a m -p o s itiv e , b u t n e v e r g r a m -n e g a tiv e , b a c te r ia , s u c h a s
m e m b e r s o f th e g e n e r a B a c illu s a n d C lo s tr id iu m , a r e s p o r e fo r m e r s .
T h e s p o r e c o n ta in s a c o m p le te c o p y o f th e c h r o m o s o m e , th e b a r e
m in im u m c o n c e n tr a tio n o f e s s e n tia l p r o te in s a n d rib o s o m e s , a n d a
h ig h c o n c e n tr a tio n o f c a lc iu m b o u n d to d ip ic o lin ic a c id .

• b o th s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • b o th s ta te m e n ts a r e tr u e
S p o r e s ( o r e n d o s p o r e s ) a r e t h e m o s t r e s is ta n t b io lo g ic a l fo r m k n o w n to e x is t.
S o m e g r a m - p o s it iv e , b u t n e v e r g r a m - n e g a t iv e , b a c te r ia , s u c h a s m e m b e r s o f
th e g e n e r a B a c illu s ( e .g ., Bacillus anthracis) a n d C lo s t r id iu m ( e . g ., Clostridium
tetani o r b o tu lin u m ) , a r e s p o r e fo r m e r s . U n d e r h a r s h e n v ir o n m e n t a l c o n d itio n s ,
s u c h a s t h e lo s s o f a n u tr itio n a l r e q u ir e m e n t, th e s e b a c te r ia c a n c o n v e r t fr o m a
v e g e t a t iv e s ta te to a d o r m a n t s ta te , o r s p o r e . W h e n a s p o r e - f o r m in g
b a c te r iu m ( S F B ) s e n s e s t h a t t o u g h t im e s a r e c o m in g , a s e r ie s o f c o m p le x
e v e n ts a r e t r ig g e r e d t h a t le a d t o th e f o r m a t io n o f a s p o r e .
T h e s p o r e c o n t a in s a c o m p le t e c o p y o f t h e c h r o m o s o m e , t h e b a r e m in im u m
c o n c e n t r a t io n o f e s s e n tia l p r o te in s a n d r ib o s o m e s , a n d a h ig h c o n c e n t r a t io n o f
c a lc iu m b o u n d to d ip ic o lin ic a c id .

E x a m p le : B a c te r ia l e n d o s p o r e is a h e a t - r e s is t a n t s p o r e fo r m e d w ith in th e
c e ll. The e n d o s p o re is a c o m p le x , m u lt ila y e r e d s tru c tu re c o n ta in in g
p e p t id o g ly c a n w ith in its c o m p le x s p o r e c o a t a n d c a lc iu m d ip ic o lin a t e w ith in its
c o r e . T h is b a c te r ia l e n d o s p o r e is v e r y d iffic u lt to d e s tr o y ( m o r e s o th a n H IV ,
H B V , a n d T B v ir u s e s ) . T o d e s t r o y t h e b a c te r ia it m u s t b e a u to c la v e d a t th e
p r o p e r t e m p e r a t u r e ( 1 2 1 ° C f o r 2 0 m in u te s ) .
m 1. B y m e a n s o f a p r o c e s s c a lle d a s e x u a l r e p r o d u c tio n , s p o r e s a r e
a b le t o g r o w in t o n e w o r g a n is m s w it h o u t u n it in g w it h a n o th e r
r e p r o d u c tiv e c e ll.
2 . A c tiv e s p o r e s h a v e th in c e ll w a lls ; d o r m a n t s p o r e s h a v e th ic k ,
s tr o n g c e ll w a lls .
3 . A n th r a x is c a u s e d b y Bacillus anthracis. B o tu lis m , g a s
g a n g r e n e , a n d te ta n u s a r e c a u s e d b y Clostridium botulinum, C.
perfringens, and C. tetani, r e s p e c tiv e ly .
b a c te r ia 57

O n e o f th e m o s t c o m m o n fo r m s o f “t r a v e le r 's d ia r r h e a ” is c a u s e d by
a n e n te r o to x in p ro d u c e d b y :

• b a c t e r o id e s
• Escherichia coli
• n e is s e r ia
• e ik e n e lla

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • Escherichia co li
E. coli p r o d u c e s a n e n t e r o t o x in w h ic h c a u s e s t r a v e le r 's d ia r r h e a , a n d is a n
im p o r t a n t e t io lo g ic a g e n t in in fa n tile d ia r r h e a in d e v e lo p in g c o u n tr ie s . T h is
e n t e r o t o x in can be d e te c te d u s in g th e E L IS A . The e n z y m e - lin k e d
im m u n o s o r b e n t a s s a y , w h ic h is c o m m o n ly a b b r e v ia t e d t o E L IS A , is a
t e c h n iq u e t h a t p r o m o t e s t h e b in d in g o f th e t a r g e t a n tig e n o r a n t ib o d y t o a
s u b s tr a te , f o llo w e d b y t h e b in d in g o f a n e n z y m e - lin k e d m o le c u le t o th e b o u n d
a n tig e n o r a n tib o d y . T h e p r e s e n c e o f th e a n tig e n o r a n t ib o d y is r e v e a le d b y
c o lo r d e v e lo p m e n t in a r e a c tio n t h a t is c a t a ly z e d b y th e e n z y m e w h ic h is
b o u n d t o t h e a n t ig e n o r a n tib o d y .
T h e E L IS A p r o c e d u r e h a s m a n y a p p lic a tio n s . T h e p r o c e d u r e c a n p r o v id e
q u a lit a t iv e ( “ y e s o r n o ” ) a n d q u a n t it a t iv e (“ h o w m u c h ” ) in f o r m a t io n o n a m y r ia d
o f p r o k a r y o t ic a n d e u k a r y o t ic a n tib o d ie s . S e r u m c a n b e s c r e e n e d a g a in s t a
b a tt e r y o f a n t ig e n s in o r d e r t o r a p id ly a s s e s s t h e r a n g e o f a n t ib o d ie s t h a t m ig h t
b e p r e s e n t. F o r e x a m p le , E L IS A h a s p r o v e n v e r y u s e f u l in th e s c r u t in y o f
s e r u m f o r th e p r e s e n c e o f a n t ib o d ie s to t h e H u m a n im m u n o d e f ic ie n c y
v iru s .
1. S . aureus and Vibrio cholerae a ls o p r o d u c e e n t e r o t o x in s t h a t c a n
b e d e t e c t e d u s in g th e E L I S A a s s a y .
2 . B a c te r ia l t o x in s a r e th e m o s t p o te n t p o is o n s k n o w n , a n d t h e ir
p o t e n c y is p a r a lle le d b y t h e ir e f f ic ie n c y a s a n tig e n s .
b a c te r ia 58

W h ic h o f th e fo llo w in g s ta te m e n ts r e g a r d in g b a c te r ia l c e ll s tr u c tu r e s
is N O T tru e ?

• th e p la s m a m e m b r a n e h e lp s in e le c tr o n t r a n s p o r t a n d e n e r g y p r o d u c tio n
• fim b r ia e h e lp in m o tility o f b a c te r ia

• p e p tid o g ly c a n in th e c e ll w a ll c o n fe r s r ig id it y a n d s h a p e to b a c te r ia l c e lls
• s e x p ili m e d ia te tr a n s fe r o f D N A d u r in g c o n ju g a tio n

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • f i m b r i a e h e lp in m o t il it y o f b a c t e r i a

A ll e u k a ry o tic a n d p ro k a r y o tic c e lls a re m a d e u p o f b a s ic c o m p o n e n ts th a t p e r fo rm v a r io u s fu n c tio n s .

F u n c tio n s o f ty p ic a l b a c te r ia l c e ll s tru c tu r e s :

Structure Functions
• Helps in electron transport and energy generation
• Serves as a perm eability barrier and helps in the transport of solutes
• Bears num erous enzym e system s (that take part in the biosynthesis of
Plasma DNA), cell wall polymers, and m em brane lipids
membrane • C ontains the receptors and proteins involved in chem otactic and other
sensory transduction system s
• Actin-like protein filam ents lining the inside of the m em brane determ ine the
bacterial shape and septum form ation site fo r cell division

Cell wall • C onfers rigidity and shape to cells and prevents osm otic lysis of the cell
G ram -positive protoplast
bacteria
• The peptidoglycan layer in the cell wall prevents osm otic lysis and confers
G ram -negative rigidity and shape; the outer m em brane acts as a perm eability barrier;
bacteria associated LPS (endotoxin) and proteins have variou s functions

• Prom otes attachm ent to bacterial or host surfaces and protects against
Capsule phagocytosis

• A ct as organs of locom otion and help in chem otaxis (tow ard food and aw ay
Flagella from poisons)

Fimbriae • R esponsible for adherence of b acteria to host surfaces

• M ediate attachm ent betw een donor and recipient bacteria and transfer of
Sex p ili o r F pili bacterial chrom osom es (DNA) during conjugation

70S Ribosomes • A ct as the sites of protein synthesis

(50S+30S)
Chromosome • G enetic m aterial of cell consisting of single, circular DNA haploid genom e
b a c te ria 59

G e n e tic in fo r m a tio n is e x c h a n g e d b e tw e e n b a c te r ia in th r e e w a y s :
c o n ju g a tio n , tr a n s d u c tio n , a n d tr a n s fo r m a tio n . W h ic h p ro c e s s is
d e p ic te d b e lo w ?

D o n o r B a c te r ia l

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • tra n s fo rm a tio n
T ra n s fo r m a tio n is th e m o s t p r im itiv e o f m e c h a n is m s fo r g e n e tr a n s fe r a m o n g
b a c te ria . It o c c u r s n a tu r a lly a m o n g s o m e b a c te ria . T h e r e is no re q u ire m e n t fo r c e ll-
to - c e ll c o n ta c t. T r a n s fo r m e d c e lls a re c e lls th a t h a v e in c o r p o r a te d D N A b y
tr a n s fo r m a tio n . A n e x a m p le o f th is p r o c e s s is w h e n ro u g h p n e u m o c o c c i g r o w n in th e
p r e s e n c e o f D N A fro m d e a d s m o o th p n e u m o c o c c i d e v e lo p c a p s u le s .
N o te: T h e D N A th a t is p ic k e d u p b y th e r e c ip ie n t c e ll m u s t b e d o u b le -s tra n d ed . A s
it e n te r s th e c e ll, a n in tra c e llu la r D N A a s e ( e n d o n u c le a s e ) d e g r a d e s o n e o f th e
s tra n d s . T h is h y d r o ly s is p r o v id e s th e e n e r g y to p u ll th e re s t o f D N A in to th e c e ll.
U p ta k e is d e p e n d e n t u p o n th e p r e s e n c e o f a p ro te in k n o w n a s c o m p e te n c e factor.
O n c e in s id e th e c e ll, th e n o w s in g le - s tr a n d e d D N A c a n in s e r t in to h o m o lo g o u s
r e g io n s o f th e r e c ip ie n t's c h r o m o s o m e .

1. A ll o f th e p r o c e s s e s a re s ig n ific a n t in th a t th e y b rin g a b o u t a n in c r e a s e in
th e a m o u n t o f g e n e tic v a r ia tio n w ith in a p o p u la tio n .
2. R e g a r d le s s o f th e m o d e o f e x c h a n g e , th e D N A b e c o m e s in te g r a te d in th e
h o s t c e ll c h r o m o s o m e b y re c o m b in a tio n .
3. S e x d u c tio n is g e n e tic tr a n s fe r m e d ia te d b y F - p r im e c e lls .
4. T ran s d u ctio n is th e tr a n s fe r o f g e n e tic m a te r ia l fro m o n e b a c te r ia l c e ll to
a n o th e r b y v ir a l in fe c tio n .
b a c te r ia 60

W h ic h o f th e fo llo w in g o p p o r tu n is tic a lly in fe c ts its h o s t a n d u tiliz e s

E x o to x in A ?

• Neisseria gonorrhoeae
• Helicobacter pylori
• Pseudomonas aeruginosa
• Staphylococcus aureus

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • Pseudomonas aeruginosa
Pseudomonas s p e c ie s a re u s u a lly m o tile , s tr a ig h t o r s lig h tly c u rv e d , g ra m -n e g a tiv e ,
a e ro b ic ro d s ty p ic a lly a rra n g e d in p a irs . M o s t s tr a in s a re o b lig a te a e ro b e s . T h e
p re s e n c e o f c y to ch ro m e o x id a s e in Pseudomonas s p e c ie s is u s e d to d iffe r e n tia te
th e m fro m th e E n te ro b a c te ria c e a e .
Pseudomonas aeruginosa is a n o p p o rtu n is tic p a th o g en , m e a n in g th a t it e x p lo its
s o m e b re a k in th e h o s t d e fe n s e s to in itia te a n in fe c tio n . It c a u s e s u rin a ry tra c t
in fe c tio n s , r e s p ira to r y s y s te m in fe c tio n s , d e rm a titis , s o ft tis s u e in fe c tio n s , b a c te re m ia ,
b o n e a n d jo in t in fe c tio n s , g a s tr o in te s tin a l in fe c tio n s a n d a v a r ie ty of s y s te m ic
in fe c tio n s , p a r tic u la r ly in p a tie n ts w ith s e v e re b u rn s , c a n c e r, a n d in A ID S p a tie n ts w h o
a re im m u n o s u p p re s s e d . P. aeruginosa in fe c tio n is a s e rio u s p ro b le m in p a tie n ts
h o s p ita liz e d w ith c a n c e r, c y s tic fib r o s is , a n d b u rn s .
E xo toxin A (E T A ) is b e lie v e d to b e o n e of th e m o s t im p o rta n t v iru le n c e fa c to rs
p ro d u c e d b y p a th o g e n ic s tr a in s o f P. aeruginosa. T h is to x in d is ru p ts p ro te in s y n th e s is
b y b lo c k in g p e p tid e c h a in e lo n g a tio n in e u k a r y o tic c e lls , m u c h lik e th e d ip h th e ria to x in
p r o d u c e d b y Corynebacterium diphtheriae.
A b lu e p ig m e n t, p yo c ya nin, p r o d u c e d b y P. aeruginosa c a ta ly z e s th e p r o d u c tio n of
s u p e ro x id e a n d h y d ro g e n p e ro x id e , to x ic fo rm s o f o x y g e n . T h is p ig m e n t a ls o s tim u la te s
in te rle u k in -8 (IL -8 ) re le a s e , le a d in g to e n h a n c e d a ttra c tio n of n e u tro p h ils .
A y e llo w - g r e e n p ig m e n t, p y o v e rd in , is a s id e r o p h o r e th a t b in d s iro n fo r u s e in
m e ta b o lis m . T h is p ig m e n t a ls o re g u la te s s e c re tio n o f o th e r v iru le n c e fa c to r s , in c lu d in g
e x o to x in A.
T w o e n z y m e s , L asA (s e rin e p ro te a s e ) a n d L as B (z in c m e ta llo p r o te a s e ) , a c t
s y n e r g is tic a lly to d e g r a d e e la s tin , re s u ltin g in d a m a g e to e la s tin - c o n ta in in g tis s u e s .
L ik e th e e la s ta s e s , a lk a lin e p ro te a s e c o n tr ib u te s to tis s u e d e s tr u c tio n a n d th e s p re a d
o f P. aeruginosa.
P h o s p h o lip a s e C is a h e a t- la b ile h e m o ly s in th a t b re a k s d o w n lip id s a n d le c ith in ,
fa c ilita tin g tis s u e d e s tru c tio n .
P. aeruginosa is in h e re n tly re sis ta n t to m a n y a n tib io tic s . O n ly a fe w a n tib io tic s a re
e ffe c tiv e a g a in s t P seudom onas, in c lu d in g flu o r o q u in o lo n e s , g e n ta m ic in and
im ip e n e m , a n d e v e n th e s e a n tib io tic s a re n o t e ffe c tiv e a g a in s t a ll s tra in s .
te r m s 61

W h ic h o f th e fo llo w in g is a s y m b io tic r e la tio n s h ip in w h ic h b o th

m e m b e r s o f th e a s s o c ia tio n b e n e fit?

• p a r a s it is m
• m u tu a lis m
• c o m m e n s a lis m
• m a r g in a tio n

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • m u tu a lis m
M u tu a lis m , a lo n g w it h c o m m e n s a lis m a n d p a r a s it is m d e s c r ib e t h r e e d if f e r e n t
k in d s o f s y m b io t ic r e la tio n s h ip s .
T h e te r m s y m b io s is d e s c r ib e s a c lo s e p h y s ic a l a s s o c ia t io n b e tw e e n th e
in d iv id u a ls o f t w o ( o r m o r e ) d if f e r e n t s p e c ie s . It r e s u lt s in a s ta b le c o n d itio n in
w h ic h t h e tw o o r g a n is m s liv e to g e t h e r in c lo s e p h y s ic a l p r o x im it y .
S y m b io tic r e la tio n s h ip s a r e c a te g o r iz e d a s fo llo w s :
• M u tu a lis m : A n in te r a c tio n t h a t is b e n e fic ia l t o b o t h s p e c ie s . M u t u a lis t ic
r e la t io n s h ip s c a n b e o b lig a te ( n e c e s s a r y to th e s u r v iv a l o f a t le a s t o n e o f
th e o r g a n is m s in v o lv e d ) , o r fa c u lt a t iv e ( b e n e f ic ia l b u t n o t e s s e n tia l t o th e
s u r v iv a l o f t h e o r g a n is m s in v o lv e d ) .
• C o m m e n s a lis m : L it e r a lly m e a n s “ a t t a b le t o g e t h e r ; ” t h is ty p e o f in te r a c tio n
b e n e fits o n e s p e c ie s w h ile le a v in g t h e o t h e r o n e u n a ff e c te d . O ft e n , t h e h o s t
s p e c ie s p r o v id e s a h o m e a n d / o r t r a n s p o r t a t io n f o r t h e o t h e r s p e c ie s . A
c o m m o n e x a m p le w o u ld b e th e r e m o v a l o f o x y g e n fr o m a h a b it a t, a s a
r e s u lt o f th e m e ta b o lic a c tiv itie s o f a p o p u la tio n o f f a c u lt a t iv e a n a e r o b ic
p o p u la tio n s . T h is c r e a te s a n e n v ir o n m e n t f a v o r a b le f o r th e g r o w th o f
o b lig a t e ly a n a e r o b ic p o p u la tio n s .
• P a r a s itis m : T h is is a s y m b io t ic r e la t io n s h ip b e tw e e n t w o o r g a n is m s in
w h ic h o n e s p e c ie s ( p a r a s it e ) b e n e fits in t e r m s o f g r o w th a n d r e p r o d u c tio n
to t h e h a r m o f t h e o t h e r s p e c ie s ( h o s t) . It m u s t b e e m p h a s iz e d t h a t th e
p a r a s ite a n d h o s t in te r a c t a n d t h a t e x c e s s iv e h a r m is d o n e t o a h o s t, w h ic h
m a k e s it le s s c o m p e titiv e , a n d a ls o e n d a n g e r s th e s u r v iv a l o f t h e p a r a s it e
s p e c ie s . P a r a s ite s can be d if f e r e n t ia t e d in to e c t o p a r a s it e s and
e n d o p a r a s ite s , d e p e n d in g , r e s p e c tiv e ly , o n w h e t h e r t h e y liv e o n o r in th e
h o s t. L ic e , fle a , tic k s , e tc . a r e e x a m p le s o f e c to p a r a s ite s . T a p e - w o r m s ,
s c h is t o s o m ia s is ( b ilh a r z ia s ) a n d t h e m a la r ia p a r a s ite a r e e x a m p le s o f
e n d o p a r a s ite s .
te r m s 62

F o r e a c h n u m b e r e d fu n c tio n lis te d o n th e le ft, s e le c t th e m o s t c lo s e ly

lin k e d c e ll s tr u c tu r e fro m th e lis t o n th e rig h t.

1. It c a r r ie s a m in o a c id s to th e A . M e s s e n g e r R N A (m R N A )
r ib o s o m e
B . R ib o s o m a l R N A ( r R N A )
2 . It c a r r ie s g e n e tic in fo r m a tio n fr o m
C . T ra n s fe r R N A (tR N A )
th e g e n e s to th e r e s t o f t h e c e ll
D . P la s m id s
3 . It m a k e s u p p a r t o f th e s tr u c tu r e o f
a r ib o s o m e E. T ra n s fe r m e s s e n g e r R N A (tm R N A )

4 . S p e c ia liz e d R N A th a t te r m in a te s
p r o te in s y n th e s is
5 . E x tr a c h r o m o s o m a l g e n e tic
e le m e n ts

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 - © 2 0 1 7
 • 1C, 2A , 3B , 4E , 5D
T h e b a c te r ia l g e n o m e c o n s is t s o f a ll t h e g e n e s t h a t a r e c a r r ie d b y a b a c te r iu m
b o th o n its c h r o m o s o m e a s w e ll a s o n its e x t r a c h r o m o s o m a l g e n e tic
e le m e n t s s u c h a s p la s m id s o r b a c t e r io p h a g e s ( b a c te r ia l v ir u s e s ) . U n lik e
e u k a r y o te s , w h ic h a r e d ip lo id , b a c te r ia u s u a lly a r e h a p lo id , h a v in g o n ly a s in g le
c o p y o f t h e ir c h r o m o s o m e s . B a c te r ia l g e n e s c o m p r is e c is tr o n s ( c o d in g g e n e s
w ith p r o te in s tr u c tu r e ) a n d g e n e s f o r r ib o s o m a l a n d t r a n s f e r r ib o n u c le ic a c id
( R N A ) . B a c te r ia l g e n e s a r e c lu s te r e d in to o p e r o n s , o r is la n d s , a n d w o r k in
c o o r d in a t io n f o r r e g u la tin g t h e ir f u n c t io n s a n d c o n tr o l.
T r a n s c r ip tio n is th e f ir s t s te p in p r o te in s y n t h e s is in w h ic h m e s s e n g e r R N A
(m R N A ) t r a n s c r ip ts a r e s y n th e s iz e d . T h e in fo r m a tio n in t h e g e n e t ic m e m o r y
o f th e D N A t e m p la t e is t h u s c o p ie d t o RNA ( e s p e c ia lly m R N A ) . T h is RNA
s y n t h e s is is d o n e b y t h e e n z y m e R N A p o ly m e r a s e .
M e s s e n g e r R N A ( m R N A ) is a ty p e o f R N A m o le c u le t h a t c a r r ie s g e n e tic
in fo r m a tio n ( c o d e f o r a s p e c ific a m in o a c id s e q u e n c e ) fr o m th e D N A to th e
c y to p la s m f o r th e s y n t h e s is o f p r o t e in . P r o te in s t h a t fo r m a p p r o x im a t e ly tw o -
t h ir d s o f t h e o r g a n ic m a t t e r o f a t y p ic a l c e ll a r e m a d e b y t r a n s la t in g m R N A w ith
th e a id o f r ib o s o m e s ( m o le c u la r d e c o d in g m a c h in e ).
R ib o s o m a l R N A (r R N A ) is a ty p e o f R N A m o le c u le t h a t f o r m s t h e c o m p o n e n t
o f t h e r ib o s o m e s a n d a s s is t s in p r o te in s y n th e s is . It c a t a ly z e s p e p t id e b o n d
fo r m a t io n b e tw e e n t h e in d iv id u a l a m in o a c id s .
T r a n s fe r m e s s e n g e r R N A (tm R N A ) is a s p e c ia liz e d s m a ll R N A m o le c u le th a t
b e h a v e s p a r tly lik e t R N A a n d p a r t ly lik e m R N A . It t e r m in a t e s t h e s y n t h e s is o f
p r o te in w h e n a r ib o s o m e is s ta lle d b y a d a m a g e d m R N A .
T r a n s fe r R N A (tR N A ) is a ty p e o f R N A m o le c u le w ith a ty p ic a l c lo v e r le a f
s t r u c t u r e - f o u r s h o r t b a s e - p a ir e d s t e m s a n d t h r e e lo o p s . Its fu n c t io n is t o c a r r y
a m in o a c id s t o t h e r ib o s o m e f o r p r o te in s y n th e s is . It a c ts a s a n a d a p to r
b e tw e e n t h e n u c le ic a c id a n d p r o te in la n g u a g e s .
te rm s 63

S h r in k a g e in c e ll s iz e b y lo s s o f c e llu la r s u b s ta n c e is k n o w n a s:

• a tro p h y
• h y p e r tr o p h y
• h y p e r p la s ia
• m e t a p la s ia

M IC R O B IO L O G Y /P A T H O L O G Y H *d e n ta ld e c l< S
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 atrophy
Causes of cell injury:
• Hypoxia (oxyg e n d e fic ie n c y ) a nd ischem ia (blood flo w d eficie n cy)
• Chem ical agents: in clu d in g poison s (toxins), p o llu ta n ts, in se cticid e s, ca rb o n m on oxid e,
d ru g s a nd a lcohol
• Physical agents: in clu d in g m e ch an ical trau m a, burns, fro stb ite , s u d d e n c h a n g e s in p ressure
(b a ro tra u m a ), e le c tric s h o c k a n d ra d ia tio n
• Infectious agents: b a cte ria , fu n g i, p a ra s ite s , ricke ttsia e , v iru s e s a n d p rion s
• Im m unological reactions: inclu ding a n a p h yla xis a nd loss o f im m u n e to le ra n ce th a t results
in a u to im m u n e d ise ase
• G enetic defects: h e m o g lo b in o p a th ie s (h e m o g lo b in S in sickle ce ll d ise a se ), sto ra ge
d is e a s e s (T a y-S a ch s), in b o rn e rro rs o f m e ta b o lis m (m a p le s y ru p u rin e d ise a se )
• Nutritional defects: in clu ding vita m in d eficie n cie s, o b e s ity le a din g to typ e II D M , fa t leading
to a th e ro s c le ro s is
• Aging
C ellular adaptive changes to injury:
• Atrophy (d e cre a se in cell s iz e ): is th e sh rin k a g e in cell size b y loss o f ce llu la r su b sta n ce .
C a u se s o f a tro p h y inclu de d e cre a se d w o rklo a d , p re ssu re , d im in ish e d blood s u p p ly or
nutrition, loss o f e n d o crin e stim u la tio n , and aging.
• Hypertrophy (in cre a se in ce ll s iz e ): is an in cre a se in ce ll size b y gain o f c e llu la r su b sta n ce .
H y p e rtro p h y is c a u se d e ith e r by in c re a s e d fu n c tio n a l d e m a n d o r b y sp e c ific e n d o crin e
stim ulatio n s. W ith in cre a sin g dem an d, h yp e rtro p h y can reach a lim it b e yo n d w hich
d e g e n e ra tiv e c h a n g e s a n d o rg a n fa ilu re can o ccur.
• Hyperplasia (in cre a se in cell n u m b e r): co n s titu te s an incre a se in th e n u m b e r o f ind ig e n o u s
ce lls in an o rg a n o r tissu e . P a th o lo g ica l h yp e rp la s ia is ty p ic a lly th e re su lt o f e xce ssive
e n d ocrine s tim ulatio n .
• M etaplasia (change in cell typ e ): is a “reversible” ch a n g e in w hich one a du lt cell typ e is
replaced by a n o th e r a du lt cell type. It is a ce llu la r a d a p ta tio n in w h ich ind ig e n o u s cells are
re p la ce d by ce lls th a t are b e tte r s u ite d to to le ra te a s p e c ific a b n o rm a l e n v iro n m e n t. Note:
T h e m o s t c o m m o n e p ith elial m e ta p la sia is co lu m n a r to s q u a m o u s a s o c c u rs in the
re sp ira to ry tra c t in re s p o n s e to c h ro n ic irrita tio n (e.g., in th e h a b itu a l cig a re tte
sm o k e r). Important: M e ta p la s ia is o fte n a predisposing condition to n eo plasia .
1 . Aplasia is a fa ilu re o f cell p ro d u ctio n . D uring fe ta l d e ve lo p m e n t, a p la sia re su lts in
a g e n e s is (the a b s e n c e o f an o rg a n ).
2. Hypoplasia is a d e c re a s e in cell p ro d u ctio n le ss e xtre m e th a n a p lasia .
te r m s 64

T is s u e tr a n s fe r r e d b e tw e e n g e n e tic a lly d iffe r e n t m e m b e r s o f th e

s a m e s p e c ie s is k n o w n a s a (n ):

• a u to lo g o u s g r a ft
• a llo g e n e ic g r a f t
• s y n g e n e ic g r a ft
• x e n o g e n e ic g r a ft

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I - V o lu m e 1 3 * © 2 0 1 7
 a llo g e n e ic g raft
T y p es o f G rafts:
• A u to lo g o u s g raft - s e lf tis s u e tr a n s fe r r e d fro m o n e b o d y s ite to a n o th e r in th e
s a m e in d iv id u a l (o fte n f o r b u rn s )
• S y n g e n eic g raft - tis s u e tr a n s fe r r e d b e tw e e n g e n e tic a lly id e n tic a l in d iv id u a ls
• A llo g e n e ic g raft - tis s u e tr a n s fe r r e d b e tw e e n g e n e tic a lly d iffe r e n t m e m b e r s o f
th e s a m e s p e c ie s
• X e n o g e n e ic g raft - tis s u e tr a n s fe r r e d b e tw e e n d iffe r e n t s p e c ie s
C lin ic a l M a n ife s ta tio n s o f G ra ft R ejectio n :
• H y p e ra c u te rejectio n : m in u te s to h o u rs , tis s u e n e v e r b e c o m e s v a s c u la r iz e d ,
b e c a u s e th e r e is p r e - e x is tin g h o s t s e r u m A b (Ig G ) s p e c ific fo r A g in th e g ra ft.
• A cu te re jec tion ( c e ll-m e d ia te d a llo g r a ft r e je c tio n ): d a y s to w e e k s la te r, th is
o c c u r s w h e n th e r e a r e m e m o r y C D 4 a n d C D 8 T c e lls fr o m p r e v io u s e x p o s u re s to
g ra ft.
• C h ro n ic re je c tio n : m o n th s o r y e a r s a fte r a c u te re je c tio n h a s s u b s id e d . B o th
h u m o r a l a n d c e ll m e d ia te d . A n tib o d y - m e d ia te d n e c r o s is o f g ra ft v a s c u la tu r e .
_ 1. T h e m o st fe a red c o n se q u en ce o f g r a ft th e r a p y in a p a tie n t w ith a n
im m u n o d e fic ie n c y is a g raft v ersu s h o st reactio n (G V H D ). It o c c u r s
w h e n tr a n s p la n te d im m u n o g e n ic c e lls fro m th e d o n o r a tta c k th e h o s t.
O c c u r s m o s t c o m m o n ly a fte r b o n e m a r r o w tr a n s p la n ts a n d c a n b e fa ta l.
2. W h e n a g ra ft is r e je c te d th e fir s t tim e a n d is tr ie d a g a in fro m th e s a m e
d o n o r , it w ill b e r e je c te d m o r e r a p id ly th a n th e firs t. T h is seco n d set
re jec tio n o c c u r s b e c a u s e th e in d iv id u a l h a s b e e n p r e v io u s ly s e n s itiz e d
to th e g ra ft.
3. C D 4 a n d C D 8 T c e lls e lic it m o s t o f th e d e s tr u c tio n in g r a ft re je c tio n .
4. T h e m o s t c o m m o n ty p e s o f h y p e r a c u te re je c tio n a re A B O b lo o d
m is m a tc h e s .
te r m s 65

C e llu la r d e g r a d a tio n b y e n z y m e s d e r iv e d fr o m s o u r c e s e x tr in s ic to
th e c e ll is k n o w n a s :

• n e c r o s is
• h e t e r o ly s is
• a u t o ly s is
• a p o p to s is

M IC R O B IO L O G Y /P A T H O L O G Y d f c d e n t a ld e c k s
Part 1• Volume 13 • © 2017
 • h e te ro ly s is
T h e m o r p h o lo g ic a p p e a r a n c e o f d e a d c e lls v a r y d e p e n d in g o n w h ic h o f th e tw o
p r o c e s s e s - e n z y m a tic d ig e s tio n o r p r o te in d e n a tu r a tio n - is d o m in a n t. S o m e
d e g r e e o f e n z y m a tic d ig e s tio n is n e a r ly a lw a y s p r e s e n t, a n d is m a n if e s te d b y
v a r io u s n u c le a r a n d c y to p la s m ic c h a n g e s . If e n z y m a tic d ig e s tio n d o m in a t e s ,
th e n d e a d c e lls a r e lik e ly to b e r e m o v e d c o m p le te ly . T h is p r o c e s s is
a c c o m p lis h e d b y a c tiv a t io n o f e n z y m e s n o r m a lly p r e s e n t w it h in a ff e c te d c e lls .
T h e p r o c e s s o f s e lf d ig e s t io n is k n o w n a s a u to ly s is . If e n z y m a tic d ig e s tio n is
a c c o m p lis h e d “fr o m o u ts id e ,” th e p r o c e s s is te r m e d h e te ro ly s is . H e r e th e
e n z y m e s a r e d e r iv e d fr o m th e ly s o s o m e s o f c e lls s u c h a s n e u tr o p h ils o r
m a c r o p h a g e s . Ir r e v e r s ib le d a m a g e to th e n u c le u s s h o w s it s e lf in o n e o f th r e e
p a tt e r n s :
1. K a ry o ly s is : th e r e is a g r a d u a l fa d in g a w a y o f th e b a s o p h ilic ( b lu e s ta in in g
fr o m th e h e m a t o x ilin d y e ) n u c le a r m a te r ia l, p r e s u m a b ly a s a r e s u lt o f th e
a c tiv ity o f D N a s e s .
2 . P y k n o s is : th e n u c le u s s h r in k s a n d b e c o m e s in te n s e ly b a s o p h ilic ; th e D N A
is p a c k e d in to a s o lid s h r u n k e n m a s s .
3 . K a r y o r r h e x is : th e p y k n o tic n u c le u s u n d e rg o e s fr a g m e n ta tio n and
c o m p le te ly d is a p p e a r s in 1 to 2 d a y s .
1. A p o p to s is ( a ls o k n o w n a s p r o g r a m m e d c e ll d e a th ) p la y s a r o le
o p p o s in g t h a t o f m ito s is in r e g u la tin g th e s iz e o f c e ll p o p u la tio n s .
2 . N e c r o s is is d e a th o f o n e o r m o r e c e lls , o r a p o r tio n o f tis s u e o r
o r g a n . It is th e r e s u lt o f ir r e v e r s ib le e x o g e n o u s in ju r y t h a t r e s u lts in
a n in s u ff ic ie n t b lo o d s u p p ly to th e tis s u e , w h e th e r fr o m in ju r y ,
r a d ia tio n , o r c h e m ic a ls .
3 . In a p o p to s is , in c o n tr a s t w ith n e c r o s is , th e r e is n o :
• b r e a k d o w n in th e m e c h a n is m s s u p p ly in g c e llu la r e n e r g y
• fa ilu r e in th e m a in t e n a n c e o f n o r m a l c e ll v o lu m e
• r u p tu r e o f p la s m a m e m b r a n e s
• a c u te in fla m m a to r y r e a c tio n e lic ite d b y d e a th
s u b s ta n c e s 66

In te r fe r o n s a r e s p e c ie s -s p e c ific p ro te in s .
In c o n tr a s t to a n tib o d ie s , in te r fe r o n s a r e v ir u s s p e c if ic b u t n o t h o s t
s p e c if ic .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta t e m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e firs t s ta te m e n t is tru e , th e s ec o n d is fa lse
In te r fe r o n s a r e p r o te in s p r o d u c e d in r e s p o n s e to v ir a l a n d o th e r in fe c tio n s ( in te r fe r o n -
a a n d in te r fe r o n - b ) o r o n a c tiv a tio n o f th e im m u n e r e s p o n s e ( in te r fe r o n - g ) ; th e y
p r o m o te a n tiv ir a l a n d a n ti- tu m o r r e s p o n s e s a n d s tim u la te im m u n e r e s p o n s e s .
In te rfe ro n s a re s p e c ie s -s p e c ific p ro tein s. In te r fe r o n is th e b o d y 's fir s t a c tiv e
d e fe n s e a g a in s t v ira l in fe c tio n , a n “ e a r ly w a r n in g s y s te m ” a t th e lo c a l a n d s y s te m ic
le v e ls . In a d d itio n to a c tiv a tin g a ta r g e t- c e ll a n tiv ir a l d e fe n s e to b lo c k v ir a l re p lic a tio n ,
in te r fe r o n s a c tiv a te th e im m u n e re s p o n s e a n d e n h a n c e T c e ll r e c o g n itio n o f th e
in fe c te d c e ll. N o te: In c o n tr a s t to a n tib o d ie s , in te r fe r o n s a re no t v iru s s p e c ific but
h ost s p ecific.
In te r fe r o n c o m p r is e s a fa m ily o f p ro te in s th a t c a n b e s u b d iv id e d a c c o r d in g to s e v e r a l
p r o p e r tie s , in c lu d in g s iz e , s ta b ility , c e ll o f o r ig in , a n d m o d e o f a c tio n . M o s t in te r fe r o n s
a re c la s s ifie d a s a lp h a , b e ta , o r g a m m a - in te r fe r o n s .
T h era p e u tic u ses of in terfero n s:
1 . In te rfero n s a lp h a a n d b e ta h a v e b e e n u s e d to tr e a t v a r io u s v ira l in fe c tio n s . O n e
c u r r e n tly a p p r o v e d u s e fo r v a r io u s ty p e s o f a lp h a in te r fe r o n is in th e tr e a tm e n t o f
c e r ta in c a s e s o f a c u te a n d c h r o n ic h e p a titis C a n d c h r o n ic h e p a titis B.
2. In te rfero n g a m m a h a s b e e n u s e d to tr e a t a v a r ie ty o f d is e a s e s in w h ic h
m a c r o p h a g e a c tiv a tio n m ig h t p la y a n im p o r ta n t ro le in r e c o v e r y (e .g .,
le p r o m a to u s le p r o s y , le is h m a n ia s is , to x o p la s m o s is ) .
3. S in c e in te r fe r o n s h a v e a n ti-p ro life r a tiv e e ffe c ts , th e y h a v e a ls o b e e n u s e d to
tr e a t c e r ta in tu m o rs s u c h a s m e la n o m a a n d K a p o s i's s a r c o m a .
1. In te rfe ro n , ly s o z y m e , c o m p le m e n t, e tc . a re p a rt o f th e n o n -s p e c ific
im m u n e s y s te m a n d a r e in d u c e d a t a n e a r ly s ta g e in v ira l in fe c tio n -
b e fo r e th e s p e c ific im m u n e s y s te m h a s h a d tim e to r e s p o n d .
2. In te r fe r o n s th e m s e lv e s a re no t a n tiv ir a l a n tib o d ie s . T h e im m e d ia te
e ffe c ts o f in te r fe r o n a re to in te rfe re w ith v ira l re p lic a tio n b y th e
in fe c te d c e ll, a n d to s ig n a l n e ig h b o r in g u n in fe c te d c e lls th a t th e y to o
s h o u ld p r e p a r e to r e s is t a v ira l in fe c tio n .
3. In te r fe r o n s a re m e m b e rs o f a la r g e r c la s s o f p r o te in s c a lle d cyto k in e s .
s u b s ta n c e s 67

S m a ll p o ly p e p tid e s r e le a s e d b y a c e ll in o r d e r to c h a n g e th e fu n c tio n
o f th e s a m e o r a n o th e r c e ll a r e c a lle d :

• c o lle c t in s
• c y t o k in e s
• d e fe n s in s
• e ffe c to r c e lls

M IC R O B IO L O G Y /P A T H O L O G Y !* d e n ta ld e c k s
P a r t I 'V o lu m e 13 * © 2 0 1 7
 • c y to k in e s
C e lls a n d p r o t e in s in d a m a g e d t is s u e s e n s e th e p r e s e n c e o f b a c t e r ia a n d th e
c e lls s e n d o u t s o lu b le p r o t e in s c a lle d c y t o k in e s t h a t in te r a c t w it h o t h e r c e lls to
t r ig g e r th e in n a te im m u n e r e s p o n s e . T h e o v e r a ll e ff e c t o f th e in n a te im m u n e
r e s p o n s e is to in d u c e a s ta te o f in f la m m a t io n in th e in fe c te d tis s u e . C y t o k in e s
b in d to s p e c if ic r e c e p t o r s o n t h e ir ta r g e t c e lls . N o te : U n lik e e n d o c r in e
h o r m o n e s , w h ic h c a n a c t t h r o u g h o u t th e b o d y , m o s t c y t o k in e s a c t lo c a lly ,
n e a r th e c e lls th a t p r o d u c e d th e m .
In n a te a n d im m u n e c e lls c o m m u n ic a t e b y in t e r a c t io n s o f s p e c if ic c e ll r e c e p to r s
w ith s o lu b le m o le c u le s , in c lu d in g c y to k in e s , in te r fe r o n s , a n d c h e m o k in e s .
 F o u r M a j o r C a te g o rie s o f C y to k in e s

P ro d u c ed by U se /F u n c tio n

In terferon s:
- Alpha Tlie buffy coat layer from white blood cells • Treatm ent o f a variety o f m alignant and
immune disorders
- Beta Fibroblasts • Currently being evaluated in the treatment
o f m ultiple sclerosis
* Gamma Activated T ceils and natural killer cells • Important immunoregulatory molecule,
particularly in allergic diseases

Colony S tim ulating F actors:

Stimulates a variety of hematopoietic precursors.
- Interleukin-3 T helper cells
Being evaluated as a therapy in aplastic anemia and
bone marrow transplantation
- Granulocyte / M acrophage CSF Regulate the selective production of neutrophils and
Lymphocytes, macrophages, fibroblasts,
- Granulocyte CSF macrophages
endothelial cells
- Macrophage CSF

T u m o r N ecrosis F actors: These molecules appear to be involved in the

- TNFa pathogenesis of septic shock and much research is
Activated macrophages
aimed at trying to inhibit their activity in septic
- TNFb Activated T cells patients. Also to treat human tumors.

Interleukins:
- IL-4 • Causes T and B cells to grow. It’s also a
A variety of cell types such as monocytes/ factor in the production o f IgF. antibodies.
- IL-5 macrophages, T cells, and B cells
• Stimulates B cells and eosinophils. It
causes B cells that produce IgA antibodies
- IL-10 to proliferate.
• Inhibits Type 1 T helper cells
s u b s ta n c e s 68

W h ic h m e ta b o lic p a th w a y is u s e d to c o n v e r t a r a c h id o n ic a c id in to
p r o s ta g la n d in s , p r o s ta c y c lin , o r th r o m b o x a n e s ?

• th e lip o x y g e n a s e p a th w a y
• th e p e n to s e p h o s p h a te p a th w a y
• th e H M G - C o A r e d u c ta s e p a th w a y
• th e c y c lo o x y g e n a s e p a t h w a y

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • t h e c y c lo o x y g e n a s e p a th w a y
A r a c h id o n ic a c id is a 2 0 - c a r b o n u n s a t u r a t e d f a t t y a c id . It is t h e m a jo r
c o m p o u n d fro m w h ic hp r o s t a g la n d in s , p r o s t a c y c lin , t h r o m b o x a n e s , a n d
le u k o tr ie n e s a r e d e r iv e d . A r a c h id o n ic a c id is a p a r t o f p h o s p h o lip id s in th e
p la s m a m e m b r a n e s o f c e lls . W h e n a c e ll is s ti m u la t e d b y a n e u r o t r a n s m it t e r o r
h o r m o n e , a p la s m a - m e m b r a n e e n z y m e c a lle d p h o s p h o lip a s e A 2 is a c tiv a te d ,
a n d t h is e n z y m e s p lit s a r a c h id o n ic a c id fr o m t h e p h o s p h o lip id s .
D iff e r e n t m e t a b o lic p a th w a y s u tiliz e d if f e r e n t enzym es th a t c o n v e rt
a r a c h id o n ic a c id in to th e d if f e r e n t m e s s e n g e r s :
•T o fo r m p r o s ta g la n d in s , p r o s ta c y c lin , or th r o m b o x a n e s , th e
c y c lo o x y g e n a s e p a t h w a y u tiliz e s th e e n z y m e c y c lo o x y g e n a s e
• T o fo r m le u k o tr ie n e s , th e lip o x y g e n a s e p a t h w a y u tiliz e s th e e n z y m e
lip o x y g e n a s e
R e m e m b e r: T h e p r o s ta g la n d in s a n d a n u m b e r o f r e la te d s u b s t a n c e s
( p r o s ta c y c lin , t h r o m b o x a n e s , a n d le u k o t r ie n e s ) a r e c h e m ic a l m e s s e n g e r s . O n e
o r a n o t h e r o f t h e m is p r e s e n t in a lm o s t e v e r y b o d y t is s u e . T h e y a c t p r im a r ily a s
lo c a l m e s s e n g e r s t h a t e x e r t t h e ir e f f e c t s in th e ti s s u e s t h a t s y n t h e s iz e th e m .
s u b s ta n c e s 69

S e r o to n in (5 -h y d r o x y tr y p ta m in e ) is a p r e fo r m e d v a s o a c tiv e
m e d ia to r w ith a c tio n s s im ila r to th o s e of:

• h e p a r in
• th r o m b in

• a c e ty lc h o lin e
• h is ta m in e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • h is ta m in e
S e r o to n in is p r e s e n t in p la te le ts a n d c e r ta in n e u r o e n d o c r in e c e lls ( e . g ., in th e
g a s t r o in t e s t in a l tr a c t) . It is s y n t h e s iz e d fr o m th e a m in o a c id t r y p t o p h a n in a 2 -
s te p m e ta b o lic p a th w a y : a h y d r o x y la tio n r e a c tio n ( r a te lim it in g s te p ) a n d a
d e c a r b o x y la tio n r e a c tio n .

T h e r e le a s e o f s e r o to n in ( a n d h is ta m in e ) fr o m p la te le ts is s tim u la t e d w h e n
p la te le ts a g g re g a te a fte r c o n ta c t w it h c o lla g e n , t h r o m b in , a d e n o s in e
d ip h o s p h a te , a n d a n t ig e n - a n t ib o d y c o m p le x e s . T h u s , t h e p la t e le t r e le a s e
r e a c tio n , w h ic h is a k e y c o m p o n e n t o f c o a g u la tio n , a ls o r e s u lts in in c r e a s e d
v a s c u la r p e r m e a b ilit y . T h is is o n e o f s e v e r a l lin k s b e tw e e n c lo tt in g a n d
in fla m m a tio n . •
S e r o to n in is w id e ly c o n s id e r e d to b e a n e u r o tr a n s m itte r . It is b e lie v e d to p la y
a r o le in t e m p e r a t u r e r e g u la tio n , in s e n s o r y p e r c e p tio n , a n d in t h e o n s e t o f
s le e p .
1. T h e c h e m ic a l n a m e f o r s e r o to n in is 5 -h y d o x y t r y p t a m in e w h ic h is o fte n
a b b r e v ia te d t o 5 - H T .
2 . E n te r o c h r o m a ffin c e lls (E C ) a re a ty p e of e n t e r o e n d o c r in e c e ll.
E n t e r o e n d o c r in e c e lls p r o d u c e h is ta m in e a n d g a s tr in a s w e ll a s s e r o to n in .
3 . In t h e p in e a l g la n d , w h ic h lie s d e e p a t t h e c e n t e r o f t h e h u m a n b r a in ,
s e r o t o n in is p r o d u c e d a s a p r e c u r s o r t o m e la to n in .
4 . S e r o to n in is a p o w e r fu l v a s o c o n s tr ic to r .
5 . S e r o to n in is s e c r e t e d in tr e m e n d o u s q u a n t it ie s by c a r c in o id tu m o rs
( tu m o r s c o m p o s e d o f c h r o m a f f in tis s u e ) .
6 . S e r o to n in a c ts a s a n in h ib ito r o f p a in p a t h w a y s in t h e s p in a l c o r d .
7 . L y s e r g ic a c id d ie t h y la m id e in te r fe r e s w it h t h e a c t io n o f s e r o to n in in th e
b r a in .
s u b s ta n c e s 70

H is ta m in e is r e le a s e d la r g e ly in p a rt b y:

• m a c ro p h a g e s
• e n te r o e n d o c r in e c e lls
• ly m p h o c y t e s
• n e u tr o p h ils
• m a s t c e lls

M IC R O B IO L O G Y /P A T H O L O G Y d J t d e n t a ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • m ast cells
T h e tw o m a jo r v aso activ e a m in e s , s o n a m e d b e c a u s e th e y h a v e im p o r ta n t a c tio n s on
b lo o d v e s s e ls , a re histam ine a n d serotonin. T h e y a re s to re d a s p re fo rm e d m o le c u le s
in c e lls a n d th e r e fo r e a re a m o n g th e firs t m e d ia to r s to b e re le a s e d d u rin g
in fla m m a tio n . T h e ric h e s t s o u rc e s o f h is ta m in e a re th e m ast cells th a t a re n o rm a lly
p re s e n t in th e c o n n e c tiv e tis s u e a d ja c e n t to b lo o d v e s s e ls . It is a ls o fo u n d in b lo o d
b a s o p h ils a n d p la te le ts . H is ta m in e is p re s e n tin m a s t c e ll g r a n u le s a n d is re le a s e d by
m a s t c e ll d e g ra n u la tio n in re s p o n s e to a v a r ie ty o f s tim u li, in c lu d in g :
• P h y s ic a l in ju ry s u c h a s tra u m a , c o ld , o r h e a t
• B in d in g o f a n tib o d ie s to m a s t c e lls , w h ic h u n d e r lie s a lle r g ic re a c tio n s
• F ra g m e n ts o f c o m p le m e n t c a lle d a n a p h y la to x in s (C 3 a a n d C 5 a )
• H is ta m in e - re le a s in g p ro te in s d e riv e d fro m le u k o c y te s
• N e u ro p e p tid e s (e .g ., s u b s ta n c e P)
• C y to k in e s (IL -1 , IL-8)
1. H is ta m in e is r e s p o n s ib le fo r th e principal sym ptom s of anaphylaxis.
2. H is ta m in e c a u s e s dilation of arterioles a n d increases the perm eability
of venules. H is ta m in e is a ls o a p o w e rfu l b ro n c h o c o n s tr ic to r .
3. H is ta m in e is s y n th e s iz e d b y th e d e c a r b o x y la tio n o f th e a m in o a c id
h is tid in e . T h is re a c tio n is c a ta ly z e d b y th e e n z y m e L -h is tid in e
d e c a rb o x y la s e .
4. M ast cells a re fo u n d in c o n n e c tiv e tis s u e a n d in e x tra c e llu la r s p a c e s n e a r
b lo o d v e s s e ls , p a r tic u la r ly in th e lu n g s .
5. H is ta m in e is chem ically sim ilar to s e ro to n in , e p in e p h rin e , a n d
n o re p in e p h rin e .
6. Serotonin is s y n th e s iz e d fro m th e a m in o a c id try p to p h a n . Its a c tio n s a re
s im ila r to h is ta m in e .
7. Bradykinin is a v a s o a c tiv e k in in th a t m e d ia te s v a s c u la r p e rm e a b ility ,
a r te r io la r d ila tio n , a n d pain (p a in fro m in fla m e d tis s u e s is a s s o c ia te d w ith
th e re le a s e o f b ra d y k in in ). It is a p o te n t vaso d ilator a n d is p ro d u c e d b y
th e a c tio n o f kallikrein ( g e n e ra te d b y a c tiv a te d H agem an factor, fa c to r
X lla ) o n an a lp h a -2 g lo b u lin (k in in o g e n ). It m a y b e in v o lv e d in b lo o d
p re s s u re re g u la tio n .
s u b s ta n c e s 71

A ll o f th e fo llo w in g s ta te m e n ts re g a r d in g p la s m in a r e tr u e E X C E P T fo r
o n e . W h ic h o n e is th e E X C E P T IO N ?

• it is a p r o te o ly tic e n z y m e
• it is f o r m e d fr o m p la s m in o g e n
• it d ig e s ts fib r in a n d fib r in o g e n
• its d e fic ie n c y c a u s e s c la s s ic h e m o p h ilia

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • its d e f ic ie n c y c a u s e s c la s s ic h e m o p h ilia
P la s m in , o r f ib r in o ly s in , is a p r o t e o ly t ic e n z y m e t h a t is f o r m e d fr o m its
in a c tiv e p r e c u r s o r p la s m in o g e n . P la s m in o g e n is a c t iv a t e d in to p la s m in
p r e d o m in a n t ly b y tis s u e p la s m in o g e n a c tiv a to r t h a t is r e le a s e d fr o m
e n d o th e lia l c e lls . P la s m in o g e n c a n a ls o b e a c t iv a t e d b y u r o k in a s e , w h ic h is
p r o d u c e d in t h e k id n e y s .
T h e p r im a r y fu n c t io n o f p la s m in is t h e ly s is o f b lo o d c lo ts . It d ig e s t s fib r in
a n d o t h e r c o a g u la n t s s u c h a s f ib r in o g e n , f a c t o r V , f a c t o r V II I, p r o th r o m b in ,
a n d f a c t o r X II.
T h e m e c h a n is m o f f ib r in o ly s is t h a t r e s to r e s t h e p a te n c y o f d a m a g e d b lo o d
v e s s e ls is a s fo llo w s :
C lo t + p la s m in o g e n + p la s m a p r o te in s

I
R e le a s e o f t is s u e p la s m in o g e n a c t iv a t o r b y th e in ju r e d t is s u e a n d v a s c u la r
e n d o t h e liu m

i
C o n v e r s io n o f p la s m in o g e n to p la s m a b y p la s m in o g e n a c t iv a t o r

I
P la s m in b r e a k s d o w n f ib r in o g e n a n d fib r in in to f ib r in d e g r a d a t io n p r o d u c ts

1
L y s is o f u n n e c e s s a r y b lo o d c lo ts fr o m th e b lo o d v e s s e ls

N o te :
H e m o p h ilia A , o r c la s s ic h e m o p h ilia , is a b le e d in g d is o r d e r c a u s e d b y th e
a b n o r m a lit y o r d e fic ie n c y o f f a c t o r V III ( 8 5 % c a s e s ) o r fa c t o r IX ( 1 5 %
c a s e s ) . It e x c lu s iv e ly a ff e c ts m a le s .
s u b s ta n c e s 72

G 6 P D d e fic ie n c y p r o v id e s p a r tia l p r o te c tio n a g a in s t m a la ria .

G 6 P D d e fic ie n c y is in h e rite d a s a n X -lin k e d r e c e s s iv e m a n n e r .

• b o th s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I " V o lu m e 1 3 * © 2 0 1 7
 • b oth s ta te m e n ts a re tru e
G lu c o s e - 6 - p h o s p h a te d e h y d r o g e n a s e ( G 6 P D ) is a c e llu la r e n z y m e th a t p la y s a n
im p o r ta n t ro le in th e h e x o s e m o n o p h o s p h a te /p e n to s e p h o s p h a te s h u n t. It p ro d u c e s
th e re d u c e d fo rm o f n ic o tin a m id e a d e n in e d in u c le o tid e p h o s p h a te (N A D P H ) w h ic h
a c ts a s a c o fa c to r fo r p r o d u c tio n o f r e d u c e d g lu ta th io n e (G S H ) b y g lu ta th io n e
r e d u c ta s e . G S H in tu r n r e d u c e s p e r o x id e s , th u s p r o te c tin g c e lls fro m o x id a tiv e
d a m a g e . A s R B C s la c k a n u c le u s , m ito c h o n d r ia , a n d o th e r o r g a n e lle s , R B C s a re
p a r tic u la r ly d e p e n d e n t o n G 6 P D a n d th e h e x o s e m o n o p h o s p h a te s h u n t to p r o te c t
a g a in s t o x id a tiv e s tr e s s b y m a in ta in in g h ig h le v e ls o f N A D P H a n d G S H .
G 6 P D d e fic ie n c y is th e m o s t p r e v a le n t e n z y m e d e fic ie n c y in h u m a n s . It is in h e r ite d
a s a n X - lin k e d re c e s s iv e d is o r d e r . It is c a u s e d b y e ith e r s u b s titu tio n o f o n e n u c le o tid e
in th e g e n e th a t is lo c a te d o n th e te lo m e r ic re g io n o f th e lo n g a rm o f th e X
c h r o m o s o m e , o r b y in s u ffic ie n t p ro d u c tio n o f G 6 P D .
G 6 P D d e fic ie n c y is m o s t c o m m o n ly fo u n d in m a le s w h ile fe m a le s th a t a re
h e te r o z y g o u s o r h o m o z y g o u s fo r th e g e n e m a y s h o w c lin ic a l p r e s e n ta tio n o f th e
d is e a s e . M o s t in d iv id u a ls w ith G 6 P D d e fic ie n c y a re n o t a n e m ic a n d h a v e n o c lin ic a l
s y m p to m s . U s u a l p r e s e n ta tio n o f G 6 P D d e fic ie n c y in c lu d e s h e m o ly tic a n e m ia ,
ja u n d ic e , a n d r e c u r re n t b a c te r ia l in fe c tio n s .
T h e p r e v a le n c e o f G 6 P D d e fic ie n c y c o rr e la te s w ith th e g e o g r a p h ic d is tr ib u tio n o f
m a laria . G 6 P D d e fic ie n c y p r o v id e s p a rtia l p ro tec tio n a g a in s t m a la ria (s u rv iv a l
b e n e fit) in m a la r ia - e n d e m ic r e g io n s . T h e G 6 P D d e fic ie n t c e ll o ffe r s a d v a n ta g e s
a g a in s t m a la r ia in e ith e r o f th e fo llo w in g w a y s :
1. T h e G 6 P D d e fic ie n t h o s t c e lls w ith in a d e q u a te le v e ls o f in tr a c e llu la r N A D P H a n d
G S H le a d s to o x id a tiv e in ju r y to th e m a la r ia l p a r a s ite , Plasmodium falciparum.
T h e p a r a s ite is m o r e v u ln e r a b le to o x id a tiv e in ju r y a s it g e n e r a te s r e a c tiv e
in te r m e d ia te s , e s p e c ia lly o x id iz e d iro n in th e p r o c e s s o f b re a k in g d o w n
h e m o g lo b in .
2. T h e G 6 P D d e fic ie n t R B C s a re p h a g o c y to s e d b y m a c r o p h a g e s a t a n e a r lie r s ta g e
o f p a r a s ite m a tu r a tio n a s c o m p a r e d to th e n o r m a l m a la r ia - in fe c te d R B C s .
s u b s ta n c e s 73

C y to c h r o m e s a r e fo u n d in th e m ito c h o n d r ia l in n e r m e m b r a n e o f
p r o k a r y o te s .
T h e m ito c h o n d r ia l e le c tr o n tr a n s p o r t p r o te in s a r e c lu s te r e d in to
c o m p le x e s k n o w n a s C o m p le x I, II, III a n d IV .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tru e
C y to c h r o m e s a r e h e m o p r o te in s lin k e d to a n o n p r o t e in , ir o n - b e a r in g c o m p o n e n t
(a h e m e g r o u p ) , w h ic h c a n u n d e r g o th e r e v e r s ib le o x id a tio n - r e d u c tio n r e a c tio n s
th a t y ie ld e n e r g y f o r th e c e ll. M it o c h o n d r ia c o n ta in th r e e c la s s e s of
c y to c h r o m e s : a , b, a n d c , w h ic h h a v e h e m e s o f d iff e r e n t s tr u c tu r e s .
1 . C y to c h r o m e s c o n ta in a h e m e g r o u p m a d e o f a p o r p h y r in r in g
c o n t a in in g a n a t o m o f ir o n . T h e y a r e fo u n d in th e m it o c h o n d r ia l in n e r
m e m b ra n e o f e u k a ry o te s .
2 . T h e iro n a to m o f th e h e m e g r o u p a c ts a s a n e le c tr o n c a rr ie r.
3 . U n lik e th e h e m e g r o u p s o f h e m o g lo b in , th e c y to c h r o m e iro n a to m is
r e v e r s ib ly c o n v e r te d fr o m its fe r r ic ( F e 3+) to its f e r r o u s ( F e 2+) fo r m a s
a n o r m a l p a r t o f its f u n c tio n a s a r e v e r s ib le c a r r ie r o f e le c tr o n s .
4 . T h e m it o c h o n d r ia l e le c tr o n tr a n s p o r t p r o te in s a r e c lu s te r e d in to
c o m p le x e s k n o w n a s C o m p le x I, II, III, a n d IV ( s e e c h a r t b e lo w ) .

1 ro te in ( c y to c h ro m e ) C o m p le x e s o f th e F J e c tro n T r a n s p o r t c h a in

C o m p le x E n z y m a tic F u n c tio n /N a m e F u n c tio n a l C o m p o n e n ts

I N A D H /C o Q o x idoreductase F M N ; F e-S cluste rs

II S u ccinate/C o Q ox idoreductase FA D ; F e-S cluste rs

(su ccinate dehydrogenase)

m C o Q -cy toch ro m c c o x idoreductase C y toch ro m es b , c ytochrom es c l, F e-S cluste rs

rv C y toc h ro m e c oxidase C y toch ro m es a an d a3

Im p o r ta n t: C y to c h r o m e o x id a s e is th e te r m in a l e n z y m e in th e c h a in o f e v e n t s
th a t c o n s titu te s c e llu la r o x y g e n c o n s u m p tio n .
s u b s ta n c e s 74

W h ic h in te rle u k in fa v o r s T H -1 ty p e r e s p o n s e s a n d c o u n te r a c ts th e
a c tio n o f IL -1 0 ?

• IL-1
• IL-2
• IL -6
• IL -1 2

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • IL -1 2
T h e m a in im m u n e c y t o k in e s a r e t h e in te r fe r o n s ( IF N s ) a n d t h e in te r le u k in s
( IL [a k a , ly m p h o k in e s ]) . T h e r o le o f in t e r le u k in s is to m e d ia te a n d c o n tr o l th e
im m u n o lo g ic a n d in f la m m a t o r y r e s p o n s e . T h e r e a r e a t le a s t 1 8 k n o w n
in te r le u k in s m o s t o f w h ic h h a v e o n ly b e e n d is c o v e r e d in t h e la s t f e w y e a r s .

I l ie R o l e » f Hit* I n t c r l e u k i i

In te rle u k in C e llu la r so u rce A ction

IL -1 M acro p h ag e s S i m ila r to t h a t o f T N F , i.e ., to in d u c e a n d p r o m o te th e in f la m m a to r y r e a c tio n

in r e s p o n s e to G r a in - n e g a tiv e b a c te r i a a n d o th e r in f e c tio u s m ic r o o rg a n is m s .

n.-2 H e lp e r T - c e lls S t im u la te s th e p r o lif e r a t io n a n d a c tiv a tio n o f T c e lls a n d B c e lls .

IL -3 T -c e lU S tim u la te s th e g ro w th a n d d if f e r e n tia tio n o f h e m a to p o ie tic c e lls , w h ic h m a tu re

in to le u k o c y te s , g ra n u lo c y te s , e ry th r o c y te s , e tc .

IL -4 H e lp e r T -c e lls P r o m o t e s B - c e ll a c tiv a tio n a n d d if f e r e n ti a ti o n . I t 's a ls o a f a c to r in th e

p ro d u c tio n o f I g E a n tib o d ie s .

1 L -5 H e lp e r T -c e lls S tim u la te s B - c e lls , a n d e o s in o p h ils . I t c a u s e s B - c e lls th a t p r o d u c e Ig A

a n tib o d ie s to p r o life ra te .

IL -6 T -c e lls W o r k s in c o m b in a t io n w ith in te r fe ro n - a lp h a to in d u c e B - c e ll d if f e r e n ti a ti o n .

M a c ro p h ag e s P ro d u c e s fe v e r, s tim u la te s h e lp e r T -c e lls .

il -7 S tro m a l c e lls C a u s e s ly m p h o i d s te m c e lls t o d if f e r e n ti a te in to p r o g e n it o r T - a n d B - c e lls .

IL -8 M acro p h ag e s I L -8 is “ s tic k y " fo r T - c c lls a n d n e u tro p h ils a n d h e lp s b r in g t h a n to th e s it e o f

E n d o th e lia l c e lls in f la m m a tio n .

IL -1 0 T - a n d B - c e lls In h ib its th e p r o d u c tio n o f m a c r o p h a g e - d e r iv e d T N F a n d I L -1 2 . th u s

M o n o c y te s s u p p r e s s in g in f la m m a to ry r e a c tio n s a s w e ll a s th e T H - l p a th w a y o f T h e lp e r

M a c ro p h ag e s c e ll d if fe re n tia tio n .

IL -1 2 M o n o c y te s F a v o rs T H - l r e s p o n s e s , w ith m a c r o p h a g e a n d N K c e ll a c tiv a tio n : in d u c e s

in te r fe ro n - g a m m a p ro d u c tio n .
s u b s ta n c e s 75

W h ic h o f th e fo llo w in g is p r e s e n t in th e s e c o n d a r y g r a n u le s o f
n e u tro p h ils ?

• la c to fe r r in
• p r o te o ly tic e n z y m e s
• n u c le o tid a s e
• c a ta la s e

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • lactoferrin
L a c to ferrin is a n ir o n - b in d in g g ly c o p r o te in th a t b e lo n g s to th e tr a n s fe r r in fa m ily . It is
fo u n d in h ig h c o n c e n tr a tio n s in c o lo s tr u m a n d b r e a s t m ilk . It is a ls o p r e s e n t in th e
s e c o n d a ry g r a n u le s o f n e u tr o p h ils . L a c to fe r rin h a s b a c te r io s ta tic p r o p e r tie s . A s an
iro n c h e la to r , la c to fe r rin h a lts b a c te r ia l g r o w th b y d e p r iv in g b a c te r ia o f iro n , an
im p o r ta n t n u tr ie n t r e q u ire d fo r g r o w th . L a c to fe r rin a ls o p la y s a ro le in n e u tr o p h il
d e g r a n u la tio n , oxygen ra d ic a l p r o d u c tio n , n e u tr o p h il- e n d o th e lia l a d h e s io n
in te r a c tio n s , n e u tr o p h il a g g r e g a tio n , c h e m o ta x is , a n d g r a n u lo c y to p o ie s is ( p r o d u c tio n
o f g r a n u lo c y te s — n e u tro p h ils , e o s in o p h ils , b a s o p h ils , a n d m a s t c e lls — in th e b o n e
m a r ro w ) .
N e u tro p h ils a ls o p la y a n im p o r ta n t ro le in b a c te r ia l d e s tr u c tio n th r o u g h p h a g o c y to s is .
G r a n u le s p r e s e n t in th e c y to p la s m o f n e u tr o p h ils , n a m e ly p rim a ry o r a z u ro p h ilic
g ran u les (s ta in p o s itiv e w ith th e a z u r e A d y e ), s e c o n d ary o r s p ec ific g ran u les,
te rtia ry o r g e la tin a s e g ra n u les , a n d se c reto ry v es icle s , h e lp in th e a n tim ic r o b ia l
fu n c tio n .
1. A z u ro p h ilic g ra n u les :
• T h e s e fo r m 3 0 % o f th e g r a n u la r c o n te n t o f m a tu r e n e u tr o p h ils .
• T h e y a p p e a r a t th e p r o m y e lo c y te s ta g e .
• T h e ir c o n te n ts in c lu d e d e fe n s in s , m y e lo p e r o x id a s e , e la s ta s e , ly s o z y m e , and
c a th e p s in G .
2. S e c o n d ary g ran u les:
• T h e s e g r a n u le s a re tw ic e a s a b u n d a n t a s a z u r o p h ilic g r a n u le s in th e c y to p la s m .
• T h e y a p p e a r a t th e b e g in n in g o f th e m e ta m y e lo c y te s ta g e .
• T h e ir c o n te n ts in c lu d e la c to fe r rin a n d c o lla g e n a s e .
3. T e rtia ry g ra n u les :
• T h e s e g r a n u le s a ls o a p p e a r a t th e m e ta m y e lo c y te s ta g e .
• T h e y c o n ta in g e la tin a s e .
4. S e c re to ry vesicle s:
• T h e s e v e s ic le s a p p e a r d u r in g th e la s t s ta g e s o f n e u tro p h il m a tu r a tio n .
c e lls /o r g a n e lle s 76

A b a c te r ia l c e ll w a ll c o m p o n e n t s u s c e p tib le to ly s o z y m e is:

• lip o p o ly s a c c h a r id e
• te ic h o ic a c id
• lip o p r o t e in
• p e p tid o g ly c a n

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • p e p tid o g ly c a n
L y s o z y m e is a n e n z y m e in h u m a n te a r s a n d m u c u s , b u t is a ls o p r o d u c e d b y
b a c t e r ia a n d o t h e r o r g a n is m s . L y s o z y m e d e g r a d e s t h e g ly c a n b a c k b o n e o f th e
p e p t id o g ly c a n ( a ls o k n o w n a s m u r e in ) . W it h o u t t h e p e p t id o g ly c a n , t h e b a c te r ia
s u c c u m b t o t h e la r g e o s m o t ic p r e s s u r e d if f e r e n c e s a c r o s s t h e c y t o p la s m ic
m e m b r a n e a n d ly s e . R e m o v a l o f t h e c e ll w a ll p r o d u c e s a p r o t o p la s t t h a t ly s e s
u n le s s it is o s m o t ic a lly s t a b iliz e d .
* * * T h e r e a r e tw o p a r ts t o th e p e p t id o g ly c a n m o le c u le :
1 . P e p tid e p o r tio n : is c o m p o s e d o f s h o r t, a tt a c h e d , c r o s s - lin k e d p e p tid e
c h a in s c o n t a in in g u n u s u a l a m in o a c id s .
2 . G ly c a n p o r tio n : f o r m s th e b a c k b o n e o f t h e m o le c u le , it is c o m p o s e d o f
a lt e r n a t e ly r e p e a tin g u n it s o f t h e a m in o s u g a r s N - a c e t y lg lu c o s a m in e a n d N -
a c e t y lm u r a m ic a c id .
* * * L y s o z y m e c le a v e s th e g ly c o s id ic b o n d b e tw e e n N - a c e t y lg lu c o s a m in e
a n d N - a c e t y lm u r a m ic a c id .
The p e p tid o g ly c a n is a m e s h lik e e x o s k e le to n s im ila r in f u n c tio n to th e
e x o s k e le to n o f an in s e c t. It is e s s e n tia l f o r t h e s tr u c tu r e , r e p lic a tio n , and
s u r v iv a l in t h e n o r m a lly h o s tile c o n d it io n s in w h ic h b a c te r ia g r o w .

Im p o r ta n t p o in ts :
1 . L y s o z y m e is a c o m p o n e n t o f t h e in n a te im m u n e s y s te m b e c a u s e :
o Its a c t io n o n p e p t id o g ly c a n s is im m e d ia t e a n d n o t p a t h o g e n s p e c if ic
° It f u n c t io n s a s a n o n - s p e c if ic in n a te o p s o n in b y b in d in g to t h e b a c te r ia l
c e ll s u r fa c e a n d e n h a n c in g p h a g o c y to s is
2 . L y s o z y m e is a ls o u s e d to p r o d u c e p r o to p la s ts o f c e r ta in b a c te r ia .
3 . P r o to p la s ts a r e c e lls t h a t h a v e h a d th e ir c e ll w a lls a n d c a p s u le s r e m o v e d
b y e n z y m a t ic ( ly s o z y m e ) o r a n t ib io t ic ( p e n ic illin ) tr e a tm e n t.
4 . A ll o t h e r b a c te r ia l c e ll w a ll c o m p o n e n t s a r e n o t s u s c e p t ib le to ly s o z y m e .
5 . P e n ic illin in h ib its t h e t e r m in a l s t e p in p e p t id o g ly c a n s y n th e s is .
c e lls /o r g a n e lle s 77

W h ic h o f th e fo llo w in g c e ll s tr u c tu r e s a c ts a s th e s ite o f m R N A
a tta c h m e n t a n d a m in o a c id a s s e m b ly ?

• n u c le o lu s
• ly s o s o m e s
• p la s m a m e m b r a n e
• g o lg i a p p a r a tu s
• r ib o s o m e s

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • r ib o s o m e s

M a jo r C e ll S tr u c tu r e s

C e ll S tru c t u r e D c s c rip tio n /F u n c tio n

M e m b ra n o u s 1

P lasm a m em b ran e S erves as a b o u n d ary o f the c e ll, m a in ta in in g its in teg rity; prote in m olecu les
e m b ed d ed in plasm a m e m b ran e p erfo rm v ario u s functions.

E n d o p lasm ic reticu lu m R ibo so m e s attach ed to rou g h E R sy n th esiz e p rote in s that leav e cells via th e G olgi
co m p lex ; sm o o th E R s yn th esiz es lip id s in c o rpo rated in ce ll m e m b ran es, steroid
h o rm o n e s, an d ce rtain ca rb o h y d rates u s e d to form gly co p ro teins.

G o lg i ap p aratu s C o m p o sed o f m e m b ran o u s sacs; sy n th esizes ca rb o h y d rates, co m b in es it w ith

pro tein , an d p ac k ag es th e p rod u c t a s g lob u les o f g ly coprotein.

L y sosom cs A c e ll's “ dig e stiv e sy stem ”

P ero x iso m es C o n ta in en z y m es th a t detox ify harm fu l su b stan ces

M ito ch o n d ria D o u b le m e m b ra n o u s s tr u c t u r e ; catab o lism ; A T P sy n thesis; a c e ll’s “p o w er p la n t

N u cleus H o u s es the genetic c o d e , w h ich in turn d ic ta tes p ro te in sy n th esis

N o n n ie m b ra n o u s

R ibosom es S ite o f m R N A attach m en t a n d a m ino ac id as se m b ly (p rote in sy n th esis)

C y to sk eleto n A cts a s a fram ew o rk to su p p o rt the ce ll an d its org an elles: fu n ctio n s in cell

m o v e m en ts; form s ce ll ex ten s io n s (m icrov illi, cilia, flagella)

N u cle o lu s P lay s an essen tial ro le in th e fo rm atio n o f rib o so m es

c e lls /o r g a n e lle s 78

A ll o f th e fo llo w in g a re fu n c tio n s o f p e r o x is o m e s E X C E P T :

• d e g r a d a tio n o f a lc o h o l
• c a ta b o liz a tio n o f lo n g - c h a in fa t t y a c id s
• c a ta b o liz a tio n o f s h o r t- c h a in fa tt y a c id s
• r e g u la t io n o f h y d r o g e n p e r o x id e ( H 20 2)

M IC R O B IO L O G Y /P A T H O L O G Y d M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • c a ta b o liz a tio n of s h o rt-c h a in fa tty a cid s
P e r o x is o m e s a r e s in g le - m e m b r a n e - e n c lo s e d o r g a n e lle s d is p e r s e d in th e c y to p la s m
o f a c e ll. T h e y a r e p r e s e n t in m o s t h u m a n c e lls , b u t a re fo u n d in h ig h c o n c e n tr a tio n s
in h e p ato c y tes a n d p ro xim a l tu b u la r c ells o f th e k id n ey. P e r o x is o m e s c o n ta in
v a r io u s e n z y m e s , s u c h a s c a talase a n d u rate o xid ase, to c a rr y o u t d iffe r e n t
fu n c tio n s . In h u m a n s , th e e n z y m e u r a te o x id a s e is n o t e x p r e s s e d , a n d u ric a c id is th e
fin a l p ro d u c t o f p u r in e c a ta b o lis m .
T h e v a r io u s c e ll fu n c tio n s th a t p e r o x is o m e s p e r fo r m a r e a s fo llo w s :
1. B re a k d o w n o f lo n g -, v e ry lo n g -, a n d b ra n c h e d -c h ain fa tty a c id s . P e r o x is o m e s
c a n n o t o x id iz e s h o r t- c h a in fa tty a c id s .
2. P ro d u c tio n a n d b r e a k d o w n o f h y d r o g e n p e r o x id e , w h ic h is a to x ic m e ta b o lite
p r o d u c e d in th e p e r o x is o m e s . T h e e n z y m e c a talas e c a ta b o lize s H20 2 into
o xyg en a n d w ater.
3. D e g ra d a tio n o f a lc o h o l in to a c e ta ld e h y d e in th e liv e r c e lls
4. S y n th e s is o f p la s m a lo g en ( s p e c ia liz e d p h o s p h o lip id ) , w h ic h is r e q u ir e d fo r th e
m y e lin a tio n o f th e n e r v e c e lls
5. S y n th e s is a n d m e ta b o lis m o f b ile a c id s
6. H e lp in c e ll r e s p ira tio n
P e r o x is o m e s a r e m o r p h o lo g ic a lly s im ila r to ly s o s o m e s , b u t d iffe r fr o m th e m in th e
fo llo w in g w a y s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

P e ro x iso m e L ys o s o m e
P e r o x is o m e m e m b r a n e is th in n e r a n d m o r e p e r m e a b le B o u n d b y a ty p ic a l lip id
th a n th a t o f ly s o s o m e s b ila y e r m e m b r a n e

T h e y a r e b e lie v e d to b e d e r iv e d fr o m e ith e r s e lf­ D e r iv e d fr o m th e G o lg i

r e p lic a tio n o r b y b u d d in g fro m th e s m o o th e n d o p la s m ic c o m p le x
r e tic u lu m
C o n ta in s h y d r o la s e s
C h ie fly c o n ta in s o x id a s e s ( d ig e s tiv e e n z y m e s ).
c e lls /o r g a n e lle s 79

A ll o f th e fo llo w in g a r e p o te n tia l c h a r a c te r is tic s o f T c e lls E X C E P T

o n e . W h ic h o n e is th e E X C E P T IO N ?

• C D 3+
• C D 4+
• C D 8+
• a n t ig e n r e c o g n itio n r e q u ir e s M H C p r o te in s
• fr o n tlin e p h a g o c y tic c e lls

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • frontline phagocytic cells

L y m p h o c y te s

T-cells Function / Characteristics

Helper T -cells (THcells) or Promote or enhance the function o f other cells (notably, B lymphocytes and
CD4* lymphocytes macrophages). Express a molecule called CD4. Recognize the antigenic peptides
in conjunction with the so-called “ MHC Class II” proteins.

Two major subtypes o f Helper T-cells known as:

T »-l cells Signal CD8 cells to differentiate into cytotoxic T-cells; signal macrophages in Type
IV (delayed) hypersensitivity reactions.

Th-2 cells Signal B-cells to differentiate into plasma cells, which produce antibodies.

Cytotoxic T-cells (Tc cells) Attack and destroy tumor cells and foreign cells. Express a molecule called CD8.
or CD8+lymphocytes Recognize the antigenic peptides in conjunction with the so-called “MHC Class I”
proteins.

Suppressor T-cells Suppress or inhibit the immune function o f other lymphocytes. Express a molecule
called CD8.

Memory T-cells Long-lived cells that recognize previously encountered T dependent antigens.

B-cells

B lymphocytes (B-cells) On antigen presentation, they differentiate into plasma cells and memory B-cells.
Express the so-called “ MHC Class II” proteins.

Plasma cells Actively secrete antibodies. Only monomeric IgM and IgD are expressed on their
surfaces as antigen receptors.

Memory B-cells Long-lived cells that are activated in response to re-exposure to antigen.

Natural Killer (NK) cells Kill virus-infected cells and tumor cells. Lack a CD3-associated TCR and surface
IgM or IgD. Are not specific to any antigen, do not need to recognize MHC
proteins. Have no memory.
1 . T c e lls la c k Ig G r e c e p to r s , b u t h a v e C D 3 - a s s o c ia te d T c e ll
r e c e p to r s ( T C R ) , w h ic h r e c o g n iz e a u n iq u e a n tig e n o n ly in
c o n ju n c tio n w ith M a jo r H is to c o m p a tib ilit y C o m p le x ( M H C ) p r o te in s .
2 . W ith o u t M H C p r o t e in s , t h e r e w o u ld b e n o p r e s e n ta tio n o f in te r n a l
o r e x te r n a l a n tig e n s to th e T c e lls . T h e im p o r ta n c e o f M H C
p r o te in s is th a t t h e y a llo w T c e lls to d is tin g u is h s e lf f r o m n o n - s e lf.
3 . Im m u n o g lo b u lin s (Ig G a n d Ig M ) r e c e p to r s a r e f o u n d in B c e lls .
4. T c e lls a r e n o t in v o lv e d in p h a g o c y to s is o r a n t ib o d y - d e p e n d e n t
c e llu la r c y t o to x ic ity .
c e lls /o r g a n e lle s 80

S u r fa c e m e m b r a n e im m u n o g lo b u lin is a m a r k e r fo r:

• m a t u r e T ly m p h o c y te s
• n e u tr o p h ils
• m a t u r e B ly m p h o c y te s
• m o n o c y te s

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • m a tu r e B ly m p h o c y te s
B c e lls a re c h a r a c te r iz e d by t h e ir s u r fa c e im m u n o g lo b u lin s . These
im m u n o g lo b u lin m a r k e r s a r e m a d e b y th e c e lls th e m s e lv e s , a n d a r e in s e r te d
in to th e s u r fa c e m e m b r a n e w h e r e th e y a c t a s s p e c ific a n t ig e n r e c e p to r s .
T h e r e a r e tw o b r o a d s u b ty p e s o f ly m p h o c y te . T h e s e a r e k n o w n a s B c e lls a n d
T c e lls . A ll o f th e m a r e d e r iv e d fr o m th e b o n e m a r r o w b u t T c e lls u n d e r g o a
p r o c e s s o f m a tu r a tio n in th e th y m u s g la n d . M a tu r e ly m p h o c y te s a ll h a v e a
s im ila r a p p e a r a n c e . T h e y a r e s m a ll c e lls w ith a d e e p ly b a s o p h ilic n u c le u s a n d
s c a n ty c y to p la s m . B a n d T c e lls c ir c u la te in th e b lo o d a n d t h r o u g h b o d y tis s u e s .
B c e lls c o m p le t e m a tu r a tio n in th e b o n e m a r r o w a n d m ig r a te to ly m p h o id
o r g a n s . T h e y h a v e a s h o r t life s p a n , r a n g in g fr o m d a y s to w e e k s . T h e s e
ly m p h o c y te s a r e c o m m itt e d to d if fe r e n tia te in to a n tib o d y -p r o d u c in g p la s m a
c e lls in v o lv e d in a n tib o d y -m e d ia te d im m u n ity . W h e n a n im m a tu r e B c e ll is
e x p o s e d to a s p e c if ic a n tig e n ( th e y r e c o g n iz e a n t ig e n b y m e m b r a n e - b o u n d
im m u n o g lo b u lin ) , th e c e ll is a c tiv a t e d . It th e n tr a v e ls to th e s p le e n o r th e ly m p h
n o d e s , d iff e r e n tia te s , a n d r a p id ly p r o d u c e s p la s m a c e lls a n d m e m o r y c e lls .
T c e lls c o m p le te m a tu r a tio n in th e th y m u s a n d b e c o m e th y m o c y te s . T h e y h a v e
a lo n g lif e s p a n , r a n g in g fr o m m o n th s to y e a r s . T h e y a r e im p o r ta n t in c e ll-
m e d ia te d im m u n ity , T y p e IV h y p e r s e n s itiv ity r e a c tio n s ( c o n ta c t d e r m a titis ) ,
a n d in th e m o d u la t io n o f a n tib o d y - m e d ia te d im m u n ity . M a jo r c la s s e s in c lu d e
H e lp e r T c e lls ( s u b c la s s e s : T y p e - 1 a n d T y p e - 2 ) , C y to to x ic T c e lls ( C D 8 +
ly m p h o c y t e s ) , M e m o r y T c e lls a n d S u p p r e s s o r T c e lls .
m 1. T c e lls la c k Ig G r e c e p to r s , b u t h a v e C D 3 - a s s o c ia te d T c e ll
r e c e p to r s ( T C R ) , w h ic h r e c o g n iz e a u n iq u e a n tig e n o n ly in
c o n ju n c tio n w it h M a jo r H is to c o m p a tib ility C o m p le x ( M H C ) p r o te in s .
2 . C D 8 + ly m p h o c y te s r e le a s e p e r fo r in s a n d in d u c e a p o p to s is
( p r o g r a m m e d c e ll d e a th ) .
3 . IL -2 p o t e n tia te s th e g r o w th o f N a tu r a l K ille r ( N K ) c e lls a n d Ig G
a n tib o d ie s e n h a n c e t h e ir c e ll e ff e c tiv e n e s s v ia a n tib o d y - d e p e n d e n t
c e llu la r to x ic it y ( A D C C ) .
m is c e lla n e o u s 81

A s u r g ic a l w o u n d c lo s e d b y a s te r ile s u tu r e w o u ld h e a l by:

• f ir s t in te n t io n
• s e c o n d in te n t io n
• th ir d in t e n tio n
• k e lo id fo r m a t io n

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • first intention
H e a lin g is th e d e s ire d o u tc o m e o f in fla m m a tio n . A s u c c e s s fu l in fla m m a to ry re sp o n se re so lve s
in ju ry o r in fe ctio n b y rapid e lim in a tio n o f b a c te ria o r fo re ig n bod ie s, b y re p a irin g d a m a g e d tissu e
w ith c o n n e ctive tissu e , a nd by sa vin g th e tis s u e 's a bility to fu n ctio n . H e a lin g differs from sim ple
re p a ir in th a t h e a lin g in vo lve s re g e n e ra tio n o f p a re n c h y m a l tissu e w h ile re p a ir b y c o n n e ctive
tissu e d o e s not. T h e b est h e a lin g o ccu rs w h e n th e in fla m m a to ry re sp o n se h as b een q u ic k and
e ffe ctive, resu ltin g in m in im a l tis s u e d am ag e.
T h e p ro ce ss o f h e a lin g b e g in s ve ry so on a fte r in fla m m a tio n sta rts. It is n o t u n c o m m o n fo r
in fla m m a tion to o c c u r at th e s a m e tim e as h ea lin g, w ith n e u tro p h ils a nd m a c ro p h a g e s e n g a g e d in
th e ir strug gle s rig h t n ext to fib ro b la s ts th at a re layin g d ow n c o lla ge n.
Healing by third intention: th e slow filling of a w ou nd ca vity o r u lce r by gra nu latio ns, w ith
s u b s e q u e n t c ic a triz a tio n (th e p ro c e s s o f s c a r fo rm a tio n ).
Healing by first intention (p rim a ry a d h e s io n o r p rim a ry u nion ): d e s c rib e s h e a lin g th a t o c c u rs in
su rg ica l w o u n d s th a t h ave b een close d w ith ste rile su ture. T h e y are clea n w o u n d s a nd a re (or,
a tle a st, h ad b e tte r be) a se p tic, so th e in fla m m a tio n d o e s n o t invo lve in fectio n.
Healing by second intention (s e c o n d a ry a d h e s io n , s e c o n d a iy u n io n ): d e s c rib e s th e p ro ce ss
o f hea lin g a w o u n d w ith o u t th e b en efit o f su rg ica l closu re . In th is case, th e w ou n d is a llo w e d to
"granulate in;” th a t is, th e w o u n d c lo se s by co n tra ctio n a nd fillin g w ith co n n e c tiv e tissue.
1. T h e m a jo r d iffe re n ce s b e tw e e n firs t a nd s e co n d in te n tio n a re th a t w o u n d s h ea lin g
by se co n d in te n tio n a re m o re o p e n a nd are m o re p ro ne to in fectio n, a nd th a t m uch
m ore granulation tissue is n e c e s s a ry to c lo se th e w o u n d . F u rth e rm o re , w h ile th e
tim in g o f th e a p p e a ra n c e o f th e v a rio u s ce ll ty p e s is th e s a m e in both cases,
hea lin g by se co n d inten tion w ill ta ke lo n g e r s im p ly b eca use th e re is a la rg e r w ou nd
to fill.
2. T h e ten sile strength of a h e a lin g w o u n d d e p e n d s upon th e fo rm a tio n o f collagen
fibers. T e n s ile s tre n g th u su a lly re a ch e s a b o u t 8 0 % o f o rig in a l s tre n g th .
3. G lucocorticoids h ave b een sh ow n to h ave th e greatest effect on g ra nu latio n
tjs s u e

4 W h e th e r a w o u n d h ea ls by p rim a ry inte n tio n o r se c o n d a ry in te n tio n is d e te rm in e d

by the nature of the w ound, ra th e r th an b y th e h e a lin g p ro ce ss itself.
m is c e lla n e o u s 82

S u s c e p tib ility to te r a to g e n s is s p e c if ic fo r e a c h d e v e lo p m e n ta l s ta g e
B E C A U S E te r a to g e n s a re d o s e d e p e n d e n t.

• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t a n d r e la te d
• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t b u t N O T r e la te d
• th e s ta te m e n t is c o r r e c t , b u t th e r e a s o n is N O T
• th e s ta te m e n t is N O T c o r r e c t , b u t th e r e a s o n is c o r r e c t
• N E IT H E R th e s ta te m e n t N O R th e r e a s o n is c o r r e c t

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • b o th th e s ta t e m e n t a n d th e re a s o n a r e c o r r e c t b u t N O T re la te d
* * * T h e f a c t t h a t t e r a t o g e n s a r e d o s e d e p e n d e n t is n o t r e la te d to th e
d e v e lo p m e n t a l s ta g e in w h ic h t h e t e r a t o g e n s a r e e n c o u n te r e d .
T e r a t o g e n ic d r u g s a c t in d if f e r e n t w a y s ; t h e y c a n in h ib it , in te r fe r e , o r b lo c k ,
m e ta b o lic s te p s c r itic a l f o r n o r m a l m o r p h o g e n e s is . M a n y d r u g s o r v ir u s e s
a f f e c t s p e c if ic tis s u e s o r o r g a n s .
T e r a t o g e n ic a g e n ts :
• P h y s ic a l a g e n ts : r a d ia tio n , h y p o x ia , e x c e s s iv e c a rb o n d io x id e , and
m e c h a n ic a l tr a u m a
• M a te r n a l in fe c t io n : (T O R C H c o m p le x ) = T o x o p la s m o s is , O th e r a g e n ts ,
R u b e lla , C y to m e g a lo v ir u s , a n d H e r p e s s im p le x
• H o r m o n e s : s e x a n d c o r t ic o s t e r o id s
• V it a m in d e fic ie n c ie s : r ib o fla v in , n ia c in , fo lic a c id , a n d v ita m in E
• C h e m o t h e r a p y d r u g s : u s e d f o r t r e a t in g m a lig n a n c ie s
• A n tib io tic s : m ito m y c in , d a c t in o m y c in , and p u r o m y c in (u s e d as
c h e m o t h e r a p y a g e n ts )
T e r a t o g e n e s is m a y b e in d u c e d w h e n a t le a s t t w o c o n d it io n s a r e m e t . F ir s tly ,
t h e te r a t o g e n m u s t g e t in t o c o n t a c t w ith th e d e v e lo p in g f e tu s . S e c o n d ly , th e
t im e t h e s e a r e in c o n t a c t m u s t b e d u r in g t h e p h a s e w h e r e t h e o r g a n s y s t e m s
a r e in p r o c e s s o f b e in g f o r m e d . T h is c r itic a l p h a s e is t h e f ir s t 3 m o n th s
fo llo w in g c o n c e p tio n , a ls o k n o w n a s t h e fir s t tr im e s te r .
T h e d o s e a n d th e t im e o f e x p o s u r e to a p a r t ic u la r a g e n t o fte n d e t e r m in e s th e
s e v e r ity o f th e d a m a g e a n d th e ty p e o f d e f e c t t h a t o c c u r s . T h e d o s e r e s p o n s e
is o b v io u s : t h e g r e a t e r t h e d o s e , t h e g r e a t e r t h e e ff e c t . T h e tim e o f e x p o s u r e
is a n o th e r im p o r ta n t c o n c e p t, as c e r ta in s ta g e s of e m b r y o n ic and fe t a l
d e v e lo p m e n t a r e m o r e v u ln e r a b le th a n o th e r s .
m is c e lla n e o u s 83

T h e s y m p to m s o f s e p s is in c lu d e a ll o f th e fo llo w in g E X C E P T o n e .
W h ic h o n e is th e E X C E P T IO N ?

• fe v e r
• w eakness
• p a in fu l u r in a tio n
• nausea
• v o m it in g

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • p a in fu l u rin a tio n
In s e v e r e b a c te r ia l in fe c tio n s ( s e p s is ) th e la rg e a m o u n ts o f o rg a n is m s a n d L P S in th e
b lo o d s tim u la te th e p r o d u c tio n o f e n o r m o u s q u a n titie s o f s e v e r a l c y to k in e s , n o ta b ly
T N F a n d IL -1 . A s a re s u lt, c irc u la tin g le v e ls o f th e s e c y to k in e s in c r e a s e a n d th e
n a tu re o f th e h o s t r e s p o n s e c h a n g e s . H ig h le v e ls o f c y to k in e s c a u s e v a r io u s c lin ic a l
m a n ife s ta tio n s s u c h a s d is s e m in a te d in tr a v a s c u la r c o a g u la tio n , c a rd io v a s c u la r
fa ilu r e , a n d m e ta b o lic d is tu r b a n c e s , w h ic h a re d e s c r ib e d a s sep tic sh o ck. C o m m o n
s ite s fo r th e o r ig in a tio n o f s e p s is in c lu d e :
• The k id n e y s ( u p p e r u r in a r y tr a c t in fe c tio n )
• The liv e r o r th e g a ll b la d d e r
• The b o w e l ( u s u a lly s e e n w ith p e r ito n itis )
• The s k in (c e llu litis )
• The lu n g s ( b a c te r ia l p n e u m o n ia )
M e n in g itis m a y a ls o b e a c c o m p a n ie d b y s e p s is . In c h ild r e n , s e p s is m a y a c c o m p a n y
in fe c tio n o f th e b o n e ( o s te o m y e litis ) . In h o s p ita liz e d p a tie n ts , c o m m o n s ite s of
in fe c tio n in c lu d e in tr a v e n o u s lin e s , s u r g ic a l w o u n d s , s u r g ic a l d r a in s , a n d s ite s o f s k in
b r e a k d o w n k n o w n a s d e c u b itu s u lc e r s o r b e d s o r e s . T h e m ain c u lp rits o f sep s is
s e e m to b e Staphylococcus aureus, Escherichia coli, a n d Klebsiella.
In a d d itio n , th e L P S (e n d o to x in ) r e le a s e d fro m th e w a lls o f d e a d g r a m - n e g a tiv e
b a c te r ia w h e n th e y a re ly s e d c a n c a u s e s e p tic s h o c k a s w e ll a s c o m p le m e n t-
a c tiv a te d a n a p h y la c tic s h o c k .
1 . B ac terem ia re fe rs to th e p r e s e n c e o f v ia b le b a c te r ia in th e c irc u la tin g
b lo o d . T h is c a n o c c u r e v e n in h e a lth y in d iv id u a ls . F o r e x a m p le , fo llo w in g
s o m e d e n ta l p ro c e d u r e s , s u c h a s a n o ra l p r o p h y la x is a n d e x tr a c tio n s ,
b le e d in g o f th e g u m s r e s u lts in a tr a n s ie n t s y s te m ic b a c te r e m ia . C lin ic a l
s ig n s a n d s y m p to m s a re u s u a lly n o t p r e s e n t.
2. V ire m ia is d e fin e d a s a v ira l in fe c tio n o f th e b lo o d s tre a m . It is a m a jo r
fe a tu r e o f d is s e m in a te d in fe c tio n s . T h e in fe c tin g v iru s is v e ry
s u s c e p tib le to c irc u la tin g a n tib o d ie s .
m is c e lla n e o u s 84

F o llo w in g lo s s o r d a m a g e to liv e r tis s u e , liv e r c e lls r e g e n e r a te b y

p r o life r a tio n o f s u r v iv in g h e p a to c y te s o r fro m r e p o p u la tio n o f
p r o g e n ito r c e lls .
L iv e r c e lls m u ltip ly c o n s ta n tly th r o u g h o u t life , a n d a r e th u s la b ile
c e lls .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y d M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • the first statem e nt is true, the secon d is false
R e g e n e r a tio n c a n b e d e fin e d a s th e a b ility o f c e rta in tis s u e s o r o rg a n s to re p la c e
d a m a g e d o r lo s t c e lls a n d e ffe c tiv e ly r e tu rn th e tis s u e o r o rg a n to a n o rm a l s ta te .
E x a m p le s in c lu d e d iv id in g e p ith e lia o f th e s k in a n d in te s tin e s , a n d p a r e n c h y m a l o rg a n s
s u c h a s th e liv e r. T h e liv e r h a s a re m a r k a b le c a p a c ity to r e g e n e ra te .
L iv e r r e g e n e r a tio n o c c u r s b y tw o m a jo r m e c h a n is m s :
1 . P roliferation of h ep ato cytes after partial hep atectom y: U p to 7 0 % o f th e liv e r m a y
b e re m o v e d d u r in g a p a rtia l h e p a te c to m y . F o llo w in g th e p ro c e d u r e , p ro life r a tio n o f th e
h e p a to c y te s ta k e s p la c e . T h is is tr ig g e r e d b y th e actio n o f both c ytokines and
p o lyp ep tide g row th facto rs. T h e w h o le p ro c e s s o c c u r s in th re e d is tin c t p h a s e s :
° In th e first o r p rim ing phase, c y to k in e s , s u c h a s IL -6 ( p r o d u c e d m a in ly b y
K u pffer cells) a c t o n h e p a to c y te s to p re p a re th e m to re c e iv e a n d r e s p o n d to
g ro w th fa c to r s ig n a ls .
" In th e seco n d p h ase, g ro w th fa c to rs (H G F a n d T G F -a ) a c t o n p rim e d h e p a to c y te s
to s tim u la te th e c e ll m e ta b o lis m , fo llo w in g w h ic h h e p a to c y te s e n te r th e c e ll c y c le .
B e in g stab le o r q uiescen t cells, h e p a to c y te s ta k e s e v e ra l h o u rs to p ro g r e s s fro m
Go to G i, a n d fin a lly re a c h th e S p h a s e o f D N A r e p lic a tio n . T h e re p lic a tio n o f
p a r e n c h y m a l c e lls ( h e p a to c y te s ) is fo llo w e d b y th e re p lic a tio n o f n o n p a r e n c h y m a l
c e lls s u c h a s K u p ffe r c e lls , e n d o th e lia l c e lls , a n d s te lla te c e lls .
• In th e fin al phase, o n c e th e liv e r m a s s is r e s to r e d , n o fu rth e r p ro life r a tio n o c c u r s
a n d th e h e p a to c y te s r e tu r n to th e ir q u ie s c e n t p h a s e .
2. R eg en eration by p ro g en ito r cells: P r o g e n ito r c e lls c o n tr ib u te to liv e r re g e n e r a tio n
w h e n th e p ro life r a tiv e c a p a c ity o f h e p a to c y te s is im p a ire d s u c h a s a fte r c h ro n ic liv e r
in ju ry o r in fla m m a tio n .
A cco rd in g to the p ro liferative cap acity of the cells, tiss ues are classified as:
1. Labile tissues: C h a ra c te r iz e d b y c o n tin u o u s ly d iv id in g c e lls . T h e y in c lu d e
h e m a to p o e tic c e lls in th e b o n e m a rro w .
2. S table tissues: M in im a l p ro life r a tiv e a c tiv ity in th e ir n o rm a l s ta te , a s c e lls a re u s u a lly
in q u ie s c e n t s ta te . T h e y m o s tly c o n s titu te p a r e n c h y m a tis s u e s , s u c h a s th e liv e r a n d
k id n e y .
3. P erm anent tissues: C h a ra c te r iz e d a s n o n -p ro life r a tiv e in p o s tn a ta l life . C a r d ia c
m u s c le c e lls a n d n e u ro n s a re s u c h tis s u e s .
m is c e lla n e o u s 85

T h e m a c r o p h a g e is th e d o m in a n t c e llu la r p la y e r in c h r o n ic
in fla m m a tio n .
T h e m o n o n u c le a r p h a g o c y te s y s te m (s o m e tim e s c a lle d th e
r e tic u lo e n d o th e lia l s y s te m ) c o n s is ts o f c lo s e ly r e la te d c e lls o f b o n e
m a r r o w o r ig in , in c lu d in g b lo o d m o n o c y te s a n d tis s u e m a c r o p h a g e s .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e

• t h e fir s t s ta te m e n t is tr u e , th e s e c o n d is f a ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y O lM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s ta te m e n ts a re tru e
T h e m o n o n u c le a r p h a g o c y te s y s te m is a d iffu s e s y s te m c o m p o s e d o f b lo o d
m o n o c y te s a n d tis s u e m a c ro p h a g e s lo c a te d in r e tic u la r c o n n e c tiv e tis s u e (e .g .,
s p le e n ) . T h e s e c e lls a re r e s p o n s ib le fo r e n g u lfin g ( p h a g o c y to s is ) a n d r e m o v in g
c e llu la r d e b r is , o ld c e lls , p a th o g e n s , a n d fo r e ig n s u b s ta n c e s fro m th e b lo o d s tr e a m . It
is a fu n c tio n a l, r a th e r th a n a n a n a to m ic a l s y s te m o f th e b o d y in v o lv e d p rim a r ily in
d e fe n s e a g a in s t in fe c tio n a n d in d is p o s a l o f th e p ro d u c ts o f th e b re a k d o w n o f c e lls .
N o te: T h is s y s te m c o n s titu te s a ll p h a g o c y tic c e lls o f th e b o d y e x c e p t g r a n u lo c y te s
in c lu d in g th e c e lls p re s e n t in th e b o n e m a r ro w , s p le e n , a n d liv e r.
E x a m p le s in c lu d e :
• M ic r o g lia : m a c ro p h a g e s o f th e C N S
• K u p ffe r c e lls : p h a g o c y tic c e lls th a t lin e th e b lo o d v e s s e ls o f th e liv e r
• A lv e o la r m a c ro p h a g e s ( d u s t c e lls ) : m a c r o p h a g e s fix e d in th e a lv e o la r lin in g o f th e
lu n g s ( a ls o c a lle d r e tic u lu m c e lls o f th e lu n g s )
• H is tio c y te s : fix e d m a c r o p h a g e s in c o n n e c tiv e tis s u e
In h erite d d is o rd e rs o f th e r e tic u lo e n d o th e lia l s y s te m - c la s s ifie d a s L ip id S to r a g e
D is e a s e s :
• G a u c h e r's disease: m o s t c o m m o n , c a u s e d b y a d e fic ie n c y o f beta-
g lu co c e re b ro sid a s e
• N ie m a n n -P ic k d is e a s e : c a u s e d b y a d e fic ie n c y o f s p h in g o m y e lin a s e (d ie
w ith in a fe w y e a r s )
• T a y -S a c h s d isease: c a u s e d b y a d e fic ie n c y o f h e x o s a m in id a s e A ( r a p id ly fa ta l)
• F a b ry 's d isease: c a u s e d b y a d e fic ie n c y in a lp h a-g a la c to s id a s e
1 . T h e a b o v e d is o r d e r s a r e m o s t c o m m o n in A s h k e n a zi Je w ish a n cestry.
2. T h e y a r e c a u s e d b y in c o m p le te ly s o s o m a l b re a k d o w n o f s p h in g o lip id s
a n d m u c o p o ly s a c c h a r id e s w ith in p h a g o c y te s , le a d in g to th e ir
a c c u m u la tio n .
3. T h e y a re a ll a u to s o m a l re c e s s iv e e x c e p t F a b r y 's d is e a s e w h ic h is X -
lin k e d r e c e s s iv e .
m is c e lla n e o u s 86

O r d e r th e s e q u e n c e o f h e a lin g . M a tc h e a c h le tte r w ith its p r o p e r

s e q u e n c e n u m b e r.

• 1 . _ _ A . E p it h e lia l b r id g e s c r o s s th e w o u n d
• 2 . _ _ B . I n fla m m a tio n s u b s id e s a n d b la n c h in g b e g in s

• 3 . _ _ C . C lo tt e d b lo o d c o v e r s th e in c is io n a n d n e u tr o p h ils a c c u m u la te a t
th e w o u n d m a r g in s
• 5 . _ _ E . In fla m m a to r y c e lls a r e e n tir e ly a b s e n t

• 4 . _ _ D . C o n n e c tiv e tis s u e b r id g e s th e w o u n d
• 6 . _ _ F. G r a n u la tio n tis s u e f ills th e in c is io n s p a c e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 1. C , 2 . A , 3 . F, 4 . D , 5 . B , 6 . E
A f t e r a s u r g ic a l w o u n d is c le a n e d a n d c lo s e d w it h s u tu r e s , h e a lin g b y fir s t
in te n tio n ( p r im a r y in te n tio n ) o c c u r s . T h e s e q u e n c e o f h e a lin g is a s fo llo w s :
1 . W ith in 2 4 h o u r s - c lo t t e d b lo o d c o v e r s t h e in c is io n a n d n e u t r o p h ils
a c c u m u la t e a t t h e w o u n d m a r g in s .
2 . 2 4 -4 8 h o u r s - e p ith e lia l b r id g e s c r o s s t h e w o u n d .
3 . 3 d a y s - m a c r o p h a g e s a r e d o m in a n t in f la m m a t o r y c e ll. G r a n u la t io n tis s u e
fills t h e in c is io n s p a c e .
4 . 5 d a y s - e p it h e liu m r e a c h e s fu ll th ic k n e s s . C o n n e c t iv e t is s u e b r id g e s th e
wound.
5 .2 w eeks - in f la m m a t io n s u b s id e s . B la n c h in g b e g in s a s in c r e a s e d
c o lla g e n iz a tio n o f t h e w o u n d p r o g r e s s e s a n d v a s c u la r it y le s s e n s .
6 . 1 m o n th - in f la m m a t o r y c e lls e n t ir e ly a b s e n t.
In a la r g e wound w h e re th e b o rd e rs ca n n o t be a p p r o x im a t e d , h e a lin g by
s e c o n d a r y in te n tio n o c c u r s . T h e s e q u e n c e o f h e a lin g is a s fo llo w s :
1. Im m e d ia t e ly - h e m o s t a s is o c c u r s a n d t h e b lo o d c lo t c o v e r s t h e s u r fa c e
a llo w in g f o r t h e fo r m a tio n o f a s c a b .
2 . Im m e d ia t e ly - a c u te in f la m m a t o r y re s p o n s e b e g in s , in c lu d in g th e
m ig r a tio n o f n e u t r o p h ils d u r in g t h e f ir s t 2 4 - 4 8 h o u r s . M a c r o p h a g e s b e c o m e
th e d o m in a n t c e ll s u b s e q u e n t ly . T h e y a r e t h e m a jo r p h a g o c y t e s t o d e b r id e
th e w o u n d . T h is a c u te r e s p o n s e la s ts u n til th e w o u n d is c o m p le t e ly
d e b r id e d .
3 . D a y s to 6 w e e k s - w o u n d c o n t r a c t io n o c c u r s a s s p e c ia liz e d fib r o b la s t s
c a lle d m y o f ib r o b la s t s c o n tr a c t. T h e wound can c o n tra c t to 5 -1 0 % o f its
o r ig in a l s iz e .
4 . D a y s to w e e k s - e p it h e liu m b r id g e s th e s u r fa c e .
5 . W e e k s to m o n th s - t h e s c a r t is s u e c o n t in u e s t o d e v e lo p , f o r m in g a s tr o n g
p a tc h . C o lla g e n iz a t io n , r e m o d e lin g a n d b la n c h in g o c c u r s .
fu n g i 87

E a c h o f th e fo llo w in g fu n g a l g e n e r a c a u s e d e r m a to p h y to s is E X C E P T
o n e . W h ic h o n e is th e E X C E P T IO N ?

• b la s to m y c e s
• m ic r o s p o r u m
• t r ic h o p h y to n
• e p id e r m o p h y to n

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b la s to m yc e s
T h e s e o r g a n is m s , c a lle d d e rm a to p h y te s , a re th e p a th o g e n ic m e m b e r s o f th e
k e r a tin o p h ilic ( k e r a tin d ig e s tin g ) s o il fu n g i. M ic r o s p o r u m a n d T r ic h o p h y to n a re
h u m a n a n d a n im a l p a th o g e n s . E p id e r m o p h y to n is a h u m a n p a th o g e n .
In fe c tio n o c c u r s b y c o n ta c t w ith a rth ro sp o re s (a s e x u a l s p o r e s fo rm e d in th e h y p h a e
o f th e p a r a s itic s ta g e ) o r c o n id ia ( s e x u a l o r a s e x u a l s p o r e s fo rm e d in th e “fr e e liv in g ”
e n v ir o n m e n ta l s ta g e ) . In fe c tio n u s u a lly b e g in s in a g r o w in g h a ir o r th e s tr a tu m
c o r n e u m o f th e s k in . D e r m a to p h y te s d o n o t g e n e r a lly in v a d e r e s tin g h a irs , s in c e th e
e s s e n tia l n u tr ie n ts th e y n e e d fo r g r o w th a r e a b s e n t o r lim ite d . H y p h a e s p r e a d in th e
h a irs a n d k e r a tin iz e d s k in , e v e n tu a lly d e v e lo p in g in fe c tio u s a r th r o s p o r e s .
In h u m a n s , d e r m a to p h y to s e s a re re fe r re d to a s “tin e a ” in fe c tio n s, a n d a r e n a m e d
w ith re fe r e n c e to th e a r e a o f th e b o d y in v o lv e d . In fe c tio n s c a n s p r e a d to o th e r a re a s ;
tin e a c o r p o r is in c h ild r e n , fo r e x a m p le , is o fte n th e r e s u lt o f a tin e a c a p itis in fe c tio n
th a t h a s s p r e a d to th e fa c e .
T in e a in fec tio n s :
• T in e a c ap itis, m o s t o fte n s e e n in c h ild r e n , is a d e r m a to p h y te in fe c tio n o f th e h a ir
a n d s c a lp
• T in e a c o rp o ris, o r rin g w o rm , o c c u r s o n th e tru n k , e x tr e m itie s a n d fa c e
• T in ea b a rb a e is a n in fe c tio n o f th e h a irs a n d s k in in th e b e a r d a n d m u s ta c h e
a re a , a n d is u s u a lly s e e n in m e n
• T in e a fa c ie i is s e e n o n th e n o n b e a r d e d p a rts o f th e fa c e
• T in e a c ru ris is a n in fe c tio n o f th e g r o in . C o m m o n ly c a lle d jo c k itch.
• T in e a p e d is (A th le te 's fo o t) is a n in fe c tio n o f th e fo o t
• T in e a m a n u u m is a d e r m a to p h y te in fe c tio n o f o n e o r, o c c a s io n a lly , b o th h a n d s
• T in e a u n g u iu m is a d e r m a to p h y te in fe c tio n o f th e n a il
T h e m o s t e ffe c tiv e a n ti-m y c o tic ( a n ti- fu n g a l) a g e n t is g ris e o fu lv in . A lth o u g h
g r is e o fu lv in is p re s c rib e d to tr e a t in fe c tio n s o f th e s k in , it c a n n o t b e a p p lie d a s a
c r e a m a n d m u s t b e ta k e n in p ill fo r m .
fu n g i 88

A ll o f th e fo llo w in g a r e p o s s ib le c h a r a c te r is tic s o f fu n g i E X C E P T o n e .
W h ic h o n e is th e E X C E P T IO N ?

• d im o r p h ic
• p r o k a r y o tic
• s e p ta te d
• s p o r u la te

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • p ro ka ry o tic
F u n g i a re e u k a ry o tic a n d h a v e a c o m p le x cell w a ll. In a d d itio n , th e y a re a ll g ra m ­
p o s itiv e a n d g r o w in S a b o u r a u d 's m e d iu m a n d c o n ta in b o th D N A an d RNA.
T w o ty p e s o f fu n g i:
1 . Y e a s ts: g r o w a s s in g le c e lls th a t r e p r o d u c e b y a s e x u a lly b u d d in g .
2. M o ld s : lo n g fila m e n ts ( h y p h a e ) w h ic h fo r m a m a t-lik e s tr u c tu r e th a t is re fe r re d to
a s m y c e liu m .
D im o rp h is m is a c h a r a c te r is tic o f s o m e fu n g i, m e a n in g th a t th e y fo r m d iffe r e n t
s tr u c tu r e s a t d iffe r e n t te m p e r a tu r e s . T h e y e x is t a s m o ld s in th e s a p r o p h y tic , fre e -
liv in g s ta te a t a m b ie n t te m p e r a tu r e s a n d a s y ea s ts in h o s t tis s u e s a t b o d y
te m p e ra tu re . T h e m a jo r d im o r p h ic fu n g i in c lu d e : B la s to m y c e s , H is to p la s m a ,
C o c c id io id e s , an d S p o ro th rix sc h en ck ii.
M o s t fu n g i r e p r o d u c e a s e x u a lly b y fo r m in g c o n id ia ( a s e x u a l s p o r e s ) fro m th e s id e s
o r e n d s o f s p e c ia liz e d s tr u c tu re s c a lle d c o n id io p h o re s . D iffe r e n t c o n id ia h e lp in th e
id e n tific a tio n o f fu n g i. E x a m p le s o f asexu al s p o res ( c o n id ia ) in c lu d e : a r th r o s p o r e s ,
c h la m y d o s p o re s , b la s to s p o re s , a n d s p o r a n g io s p o r e s .
S o m e fu n g i r e p r o d u c e s e x u a lly b y m a tin g a n d fo r m in g sexu al sp o res. E x a m p le s of
s exu al s p o re s in clu d e: z y g o s p o r e s , a s c o s p o r e s , a n d b a s id io s p o r e s .
1. A ll fu n g i e xc e p t fo r th o s e b e lo n g in g to th e c la s s z y g o m y c e te s , a re
s e p ta te d .
2. T h e c e ll w a lls o f m o s t fu n g i c o n ta in c h itin an d b -1 :3 -lin k e d g lu can .
3. S tero ls ( e r g o s te r o l) a re in th e c e ll m e m b r a n e . M o s t a n tifu n g a l a g e n ts
ta rg e t th is c o m p o n e n t o f fu n g a l c e ll m e m b r a n e s .
4. F u n g a l in fe c tio n s g e n e r a lly in itia te a ty p e IV d e la y e d h y p e r s e n s itiv ity
r e a c tio n .
5. T h e fo r m a tio n o f g ra n u lo m a s in r e s p o n s e to a fu n g a l in fe c tio n is
c o m m o n (a s s e e n in c o c c id io id o m y c o s is , h is to p la s m o s is , b la s to m y c o s is ,
e tc .).
fu n g i 89

F o r e a c h n u m b e r e d te r m o n th e le ft, s e le c t th e m o s t c lo s e ly lin k e d
d e s c r ip tio n fro m th e lis t o n th e rig h t.

1. a n a m o r p h A . c o n id ia , th e a s e x u a l r e p r o d u c tiv e
2 . a r th r o s p o r e s s tr u c tu r e t h a t is p r o d u c e d b y b u d d in g

3 . te le o m o r p h B . th e s e x u a l r e p r o d u c tiv e s ta te o f a
fu n g u s
4 . b la s to s p o r e s
C . a s e x u a l r e p r o d u c tiv e s ta te o f
fu n g u s
D . c o n id ia , w h ic h is p r o d u c e d fr o m
th e f r a g m e n ta tio n o f h y p h a l c e lls

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • 1 .C , 2 .D , 3 .B , 4 .A
F u n g i a r e e u k a r y o t e s t h a t c a n r e p r o d u c e e it h e r b y a s e x u a l o r s e x u a l d iv is io n .
T h e a s e x u a l r e p r o d u c tiv e s ta te ( m it o tic d iv is io n ) o f a fu n g u s is c a lle d
a n a m o r p h . In a s e x u a l r e p r o d u c tio n , d iv is io n o f th e h a p lo id n u c le u s ta k e s
p la c e b y m ito s is w ith th e a id o f r e p r o d u c t iv e e le m e n ts , s p o r a n g io s p o r e s a n d
c o n id ia .
C o n id ia a r e a s e x u a l r e p r o d u c t iv e e le m e n t s t h a t m a y b e p r o d u c e d b y
t r a n s f o r m a t io n o f v e g e t a t iv e y e a s t o r a s p e c ia liz e d c o n id io g e n o u s c e ll, o r b y
f r a g m e n t a t io n o f h y p h a l c e lls . B la s to s p o r e s ( b la s to c o n id ia ) a r e th e c o n id ia
fo r m e d by a b u d d in g p r o c e s s ( e .g ., y e a s t) w h e r e a s a r t h r o s p o r e s
( a r th r o c o n id ia ) a r e f o r m e d b y fr a g m e n t a t io n o f h y p h a l c e lls .

S p o r a n g io s p o r e s a r e m it o tic s p o r e s , c h a r a c t e r is t ic o f th e o r d e r M u c o r a le s ,
w h ic h a r e p r o d u c e d w ith in a s a c -lik e s tr u c tu r e c a lle d a s p o r a n g iu m . T h e
s p o r a n g iu m is a t t a c h e d to a s u p p o r t in g s p o r a n g io p h o r e .
T e le o m o r p h is th e s e x u a l r e p r o d u c t iv e s ta te o f fu n g u s a n d t h e r e p r o d u c t iv e
s t r u c t u r e s a r e c a lle d s p o r e s . S e x u a l r e p r o d u c tio n in v o lv e s th e e x c h a n g e o f
g e n e t ic in f o r m a t io n a n d fo r m a t io n o f h a p lo id s e x u a l s p o r e s b y m a tin g w ith th e
c o m p a t ib le s t r a in s o f f u n g i t h r o u g h p la s m o g a m y ( fu s io n o f c e lls ) , k a r y o g a m y
( n u c le a r f u s io n ) , a n d m e io s is ( d iv is io n ) .
fu n g i 90

T h e e n d e m ic m y c o s e s a re fu n g a l in fe c tio n s c a u s e d b y th e c la s s ic
d im o r p h ic fu n g a l p a th o g e n s H is to p la s m a c a p s u la tu m , B la s to m y c e s
d erm atitid is , C o c c id io id e s im m itis, C o c c id io id e s p o s a d a s ii, a n d
P a ra c o c c o d io id e s b ra s ilie n s is .
A ll o f th e th e s e a g e n ts p r o d u c e p r im a r y in fe c tio n in th e h e a rt, w ith
s u b s e q u e n t d is s e m in a tio n to o th e r o r g a n s a n d tis s u e s .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y !* d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • th e firs t s ta te m e n t is tru e , th e s e c o n d is fa ls e
Im p o rtan t: A ll o f th e th e s e a g e n ts p r o d u c e p r im a r y in fe c tio n in th e lu n g , w ith
s u b s e q u e n t d is s e m in a tio n to o th e r o r g a n s a n d tis s u e s . T h e s e fu n g i e x h ib it th e rm a l
d im o rp h ism (e x is t a s y e a s ts o r s p h e r u le s a t 3 7 °C a n d m o ld s a t 2 5 °C ) a n d a re
g e n e r a lly c o n fin e d to g e o g r a p h ic r e g io n s w h e re th e y o c c u p y s p e c ific e n v iro n m e n ta l o r
e c o lo g ic a l n ic h e s .

C o c c id io id o m y c o s is is a n in fe c tio u s d is e a s e c a u s e d b y in h a lin g s p o r e s o f a fu n g u s
c a lle d Coccidioides immitis. T h e d is e a s e s ta r ts o u t a s a r e s p ira to r y illn e s s a n d m a y
p r o g r e s s to a p e r s is te n t in fe c tio n . D is s e m in a te d c o c c id io id o m y c o s is is th e m o s t
s e v e re fo rm o f th e d is e a s e a n d is o fte n fa ta l. Note: C o c c id io id o m y c o s is is a ls o
re fe rre d to a s “v a lle y fe v e r ” o r “ S a n J o a q u in fe v e r .” A n tifu n g a l m e d ic a tio n s u s e d to
tr e a t d is e a s e in c lu d e : A m p h o te r ic in B, flu c o n a z o le , k e to c o n a z o le a n d itr a c o n a z o le .
B la s to m y c o s is ( a ls o c a lle d G ilc h r is t's d is e a s e o r N o rth A m e r ic a n b la s to m y c o s is ) is a
d is e a s e c a u s e d b y a fu n g u s , Blastomyces dermatitidis, w h ic h is fo u n d in p a r ts o f th e
s o u th - c e n tr a l, s o u th - e a s te r n a n d m id -w e s te rn U n ite d S ta te s . T h e in fe c tio n is s p r e a d by
in h a la tio n o f a irb o r n e c o n id ia (s p o re s ) a fte r d is tu r b a n c e o f c o n ta m in a te d so il.
B la s to m y c o s is is n o t k n o w n to be tr a n s m itte d fr o m p e r s o n to p e rs o n . F o r p e r s o n s w ith
m ild o r m o d e r a te ly s e v e re d is e a s e , itr a c o n a z o le m a y b e u s e d fo r tr e a tm e n t.
H is to p la s m o s is is a d is e a s e c a u s e d b y th e fu n g u s Histoplasma capsulatum.
H. capsulatum is fo u n d th r o u g h o u t th e w o r ld a n d is e n d e m ic in O h io a n d M is s is s ip p i
riv e r v a lle y s . In fe c tio n is u s u a lly a s y m p to m a tic , b u t it c a n c a u s e a g ra n u lo m a to u s ,
tu b e rc u lo s is -lik e in fec tio n ( p r im a r y fo rm o f d is e a s e ). It is a fr e q u e n t c a u s e of
p u lm o n a r y n o d u le s . T h e in fe c tio n m a y s p re a d th r o u g h o u t th e b o d y , _a n d th is
d is s e m in a te d fo r m , th o u g h u n c o m m o n , is q u ite s e r io u s . A n tifu n g al m e d ic atio n s u s e d
to tre a t d is e a s e in c lu d e : A m p h o te r ic in B, flu c o n a z o le a n d itra c o n a z o le .
1. In in fec te d tis s u e s , y e a s t c e lls o f H. capsulatum a re fo u n d w ith in
m a cro p h ag e s.
2. H is to p la s m o s is re s e m b le s T B , b o th c lin ic a lly a n d p a th o lo g ic a lly .
3. H. capsulatum p ro d u c e s c h la m y d o s p o re s .
4. H is to p la s m o s is an d b la s to m y c o s is a re ra re ly a c q u ire d fro m a n o th e r
in d iv id u a l.
fu n g i 91

W h ic h o f th e fo llo w in g is o p p o r tu n is tic in p a tie n ts w ith d ia b e te s ,

le u k e m ia , s e v e r e b u rn s , o r m a ln u tr it io n ?

• a s p e r g illo s is
• c r y p to c o c c o s is
• z y g o m y c o s is
• d e r m a to p h y to s e s

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a ri I • V o lu m e 13 • © 2 0 1 7
 z y g o m y c o s is

M e d ic a lly I m p o r t a n t F u n g i

T a x o n o m ic D es ig n a tio n R e p re s e n t a t iv e g e n e ra H u m a n D is e as e

Class: Zygom ycetes

_____________________________ _ J
Order: M ucorales Rhizopus, M ucor, Absidia Zygom ycosis: opportunistic in patients with
Sakseaaea diabetes, leukem ia, severe bum s, or
m alnutrition; rhinocerebral infections.

Order: Entom ophthorales Basidiobolus. Conidiobolus Zygom ycosis: subcutaneous and gastrointestinal
infections

Class: Basidiom ycetes Tcleom orphs o f Cryptococcus, Cryptococcosis and num erous mycoses
M alassezia, and Trichosporon
species.

Class: A rchiascom ycetcs Pneum ocystis jitovccii Pneum ocystis pneum onia

Class: Hem iascomycetes T eleom orphs o f C andida N um erous mycoses

species: Saccharom yces

Order: Onygenales Arthroderma (teleom orphs o f D crm atophytoses; systemic mycoses

Trichophyton and Micro-
sporum); Ajellom yccs
(teleom orphs o f Blastomyces
and Histoplasm a species)

Order: Furotiales T elcom otphs o f Aspergillus Aspergillosis

species

Order: Hypocrcales Teleomorphs o f Fusarium Keratitis and o th er invasive mycoses

species

Order: M icroascales Pseudallescheria (teleom orph Pneumonia, mycetom a, and invasive mycoses
o f Scedosporiinn species)
fu n g i 92

A ll o f th e fo llo w in g a re c la s s if ie d a s s u p e r fic ia l m y c o s e s E X C E P T
o n e . W h ic h o n e is th e E X C E P T IO N ?

• Malassezia furfur
• Aspergillus fumigatus
• Hortae werneckii
• Piedraia hortae
• Trichosporon s p p .

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 A s p e rg illu s fu m ig a tu s
( i f l l u m n n M y c o s e s a n d R e p r e s e n t a t i v e K tio lo g ic A g e n ts

S u p e rfic ia l C u ta n e o u s a n d E n d em ic M y co s es O p p o r tu n is ti c M y co s es
M ycow s S u b c u ta n e o u s M ycoses

B l a c k p ie d ra D c rm a to p h y to s c s B la s to m y c e s A sp e rg illo s is

P ie d r a ia h o r ta c M ic ro s p o ru m sp p . B la s to m y c e s d e n n a titid is A s p e r g illu s f u m ig a tu s

T in e a n ig r a T r ic h o p h y to n s p p . H is to p la s m o s is A . f la v is

H o rta c w c m c c k ii E p id e rm o p h y to n llo c c o s u m H is to p la s m a c a p s u la tu m A . n ig e r
C o c c id io id o m y c o s is A . te r m s
C o e c id io id e s im m itis /
p o sa d a sii

P ity ria s is v e rs ic o lo r T in e a u n g u iu m P e n ic illio s is C a n d id ia s is

M a la s s e z ia fu rfu r T ric h o p h y to n sp p . P c n ic illiu m m a m e tT c i C a n d id a a lb ic a n s

E . f lo c c o s iu n C . g la b ra ta
C . p a ra p s ilo s is
C . tro p ic a h s

O n y c h o m y c o s is P a ra c o c c id io id o m y c o s is C ry p to c o c c o s is
W h ite p ie d ra
T r ic h o s p o r o n sp p . C a n d id a s p p . P a ra c o c c id io id e s b ra s ih e n s ts C ry p to c o c c u s n c o lo rm a n s

A s p e rg illu s sp p .
T r ic h o s p o r o n sp p .
G e o tric h u m sp p .

M y c o tic k e ra titis T ric h o s p o ro n o s is

F u s a r i u m R p p. T ric h o s p o ro n s p p .

A s p e r g il lu s sp p .
C a n d id a sp p .

C h ro m o b la s to m y c o s is Z y g o in y c o s is

F o n s e c a e a sp p . R h i z o p u s sp p .
P h ia lo p h o ra sp p . M u c o r sp p .
A b s id ia sp p .

P n c u m o c y to s is
P n e u m o c y s tis jiro v e c ii
p a ra s ite s 93

M a la r ia in h u m a n s is c a u s e d b y o n e o f fo u r p r o to z o a n s p e c ie s o f th e
genus:

• t r ic h o m o n a s
• p la s m o d iu m

• C r y p to s p o r id iu m
• to x o p la s m a

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • p la s m o d iu m
M a la r ia is a n in fe c tio u s d is e a s e c a u s e d b y a p a r a s ite , P la s m o d iu m , w h ic h
in f e c ts r e d b lo o d c e lls . O f th e f o u r s p e c ie s o f m a la r ia , th e m o s t s e r io u s t y p e is
Plasmodium falciparum m a la r ia . It c a n b e life - th r e a te n in g . T h e o th e r th r e e
s p e c ie s o f m a la r ia (P . vivax, P. malariae, a n d P. ovale) a r e g e n e r a lly le s s
s e r io u s a n d a r e n o t life - th r e a t e n in g .

C om m on I’ i ito /.o n

P ro to z o a n D is e a s e /T ra n s m is s lo n C lin ic a l C h a r a c te r is tic s

P la s m o d iu m

V iv a x

M a la ria ' F e m a le a n o p h e le s F lu -lik e s y m p to m s (m ild fe v e r, h e a d a c h e , m u s c le

O v a le
m o s q u ito , in f e c te d b lo o d a c h e s , a n d c h ills ), e n la r g e d s p le e n , h y p e rp la s ia o f

M a la ria e p ro d u c ts ly m p h o c y te s a n d m a c ro p h a g e s . T o ta l W B C is u s u a lly
n o rm a l. C a u s e s ly sis o f e r y th ro c y te s .
F a lc ip a ru m

C ry p to s p o r id iu m p a rv u m C r y p to s p o rid io s is / O ra l-fe c a l W a te ry d ia rr h e a ; o fte n a ff e c ts u n n iu n o c o m p io m is e d

p a tie n ts (th o s e w ith A ID S )

T o x o p la s m a g o n d ii T o x o p la s m o s is /B y in g e s tin g M a y r e s e m b le a m il d c o ld o r in fe c tio u s
its c y s t (o o c y s t), w h ic h is m o n o n u c le o s is in a d u lts ; c a n c ro s s th e p la c e n ta l
f o u n d in C a t f e c e s o r b a r r i e r . M o s t c o m m o n c a u s e o f e n c e p h a l i t i s in A I D S

u n c o o k e d la m b o r p o rk p a tie n ts .

K n ta m o c b a h is to ly tic a A m e b ia s is , in te s tin a l B l o o d y , m u c u s - c o n t a i n i n g d ia tT h c a ; c a n h Iso p r o d u c e

d y s e n tc ry /O ra l-fc c a l liv e r a b s c e s s e s

G i a r d ia la in b lia G ia rd ia s is / O ra l fe c a l D ia rrh e a ; s to o l is u s u a lly d e s c rib e d a s p ro fu s e a n d

w a te ry e a rly in th e d is e a s e . L a te r in th e d is e a s e , s to o ls
b e c o m e g r e a s y , f o u l s m e lli n g , a n d o f te n llo a t.

T ri c h o m o n a s v a g in a lis T r ic h o m o n i a s i s ( v a g in i tis in F e m a le : v a g in a l d is c h a r g e , itc h in g , p a in w ith u r in a ­

fe m a le , u ie lh r itis in m a le s )/ ti o n .
S e x u a lly tr a n s m itte d d is e a s e M a le ; u r e th r a l d is c h a r g e , p a in w ith u rin a tio n

P n eu m o c y s tis c a rin il P n e u m o c y s tis p n e u m o n ia ' F e v e r, n o n - p ro d u c tiv e c o u g h , s h o rtn e s s o f b re a th

In h a la tio n ( e s p e c i a lly o n e x e r tio n ) , w e i g h t lo s s a n d n ig h t s w e a ts .

A s s o c ia te d w ith im m u n o c o m p r o m is e d in d iv id u a ls

( A ID S p a tie n ts )
p a r a s ite s 94

W h ic h o f th e fo llo w in g p r o to z o a n is th e e tio lo g ic a g e n t o f a m e b ic
d y s e n te r y ?

• Giardia lamblia
• Trichomonas vaginalis
• Balantidium coli
• Entamoeba histolytica

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • Entamoeba histolytica
A m eb iasis is a n in te s tin a l illn e s s c a u s e d b y a m ic r o s c o p ic p a r a s ite c a lle d Entamoeba
histolytica. E. histolytica e x is ts in tw o fo rm s d u r in g its life c y c le : th e a c tiv e p a r a s ite
( tro p h o z o ite ) a n d a d o r m a n t p a r a s ite (c y s t). T h e m a in a ttr ib u te o f E. histolytica th a t is
r e s p o n s ib le fo r its w o r ld w id e d is trib u tio n m a y b e d u e to th e e x tre m e s ta b ility o f its c y s t in
th e e n v iro n m e n t. C o n ta m in a te d w a te r is th e m o s t c o m m o n m o d e o f th e s p re a d o f th is
in fe c tio n . A c u te in te s tin a l a m e b ia s is p re s e n ts a d ysen tery (i.e ., b lo o d y , m u c u s -c o n ta in in g
d ia rrh e a ). Note: E. histolytica c a n a ls o p ro d u c e liver (h e p a tic ) abscesses. It is tr e a te d
w ith m e tr o n id a z o le .
G iard iasis is a d ia rr h e a l illn e s s c a u s e d b y a fla g e lla te d p ro to z o a n Giardia lamblia. It a ls o
e x is ts in tw o fo rm s (tro p h o z o ite a n d c y s t). G ia rd ia in fe c tio n h a s b e c o m e r e c o g n iz e d a s o n e
o f th e m o s t c o m m o n c a u s e s o f w a te r b o rn e d is e a s e (fo u n d in b o th d rin k in g a n d
r e c r e a tio n a l w a te r) in h u m a n s in th e U n ite d S ta te s . It is m o re c o m m o n in m a le
h o m o s e x u a ls a n d in p e o p le w h o h a v e tr a v e le d to d e v e lo p in g c o u n trie s . It is tr e a te d w ith
m e tr o n id a z o le .
T rich o m o n ias is is a s e x u a lly tr a n s m itte d d is e a s e o f th e v a g in a (in w o m e n ) o r u re th r a (in
m e n ) c a u s e d b y a fla g e lla te d p r o to z o a n Trichomonas vaginalis. T. vaginalis o n ly e x is ts
a s a tro p h o z o ite . T ric h o m o n ia s is is o n e o f th e m ost com m o n in fe c tio n s w o r ld w id e .
S y m p to m s a re m o re c o m m o n in w o m e n . It is a ls o tre a te d w ith m e tr o n id a z o le .
1. E n ta m o e b a a n d T r ic h o m o n a s s p e c ie s a re fo u n d in th e o ra l c a v ity . T h e y
a p p e a r to b e n o n pa th o g e nic w h e n lo c a te d h e re .
2. Balantidium coli is a c ilia te d p ro to z o a n th a t c a n in fe c t th e c o lo n c a u s in g
d ia r rh e a w ith a c c o m p a n y in g a b d o m in a l c o lic , n a u s e a , a n d v o m itin g w ith
b lo o d y s to o ls .
3. B. coli is k n o w n fo r b e in g th e larg est p roto zo an p a r a s ite o f h u m a n s .
Rem em ber: P ro to z o a a re s im p le m ic r o o r g a n is m s th a t ra n g e in s iz e fro m 2 to 1 0 0 m m .
T h e y a re u n ic e llu la r e u k a r y o tic o rg a n is m s . T h e ir p ro to p la s m is e n c lo s e d b y a c e ll
m e m b r a n e a n d c o n ta in s n u m e r o u s o rg a n e lle s , in c lu d in g a m e m b r a n e - b o u n d n u c le u s , an
e n d o p la s m ic re tic u lu m , fo o d -s to r a g e g ra n u le s , a n d c o n tr a c tile a n d d ig e s tiv e v a c u o le s . T h e
n u c le u s c o n ta in s c lu m p s o r d is p e r s e d c h ro m a tin a n d a c e n tr a l k a ry o s o m e . O r g a n s of
m o tility v a r y fro m s im p le c y to p la s m ic e x tru s io n s o r p s e u d o p o d s to m o re c o m p le x
s tr u c tu r e s , s u c h a s fla g e lla o r c ilia . T h e k in g d o m P r o to z o a c o m p ris e s 13 m a jo r s u b g ro u p s ,
o r p h y la .
p a ra s ite s 95

W h ic h o f th e fo llo w in g d is e a s e s is a z o o n o ti in fe c tio n tr a n s m it te d
fr o m c a ts ?

• t o x o p la s m o s is
• h is to p la s m o s is
• tr ic h o m o n ia s is
• a ll o f th e a b o v e

M IC R O B IO L O G Y /P A T H O L O G Y d M e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • to x o p la s m o s is
Z o o n o s is is a n in fe c tio n t h a t c a n b e t r a n s m it t e d fr o m a n im a ls to h u m a n s .
E x a m p le s o f z o o n o s e s in c lu d e to x o p la s m o s is , w h ic h is t r a n s m itte d
th r o u g h c a ts , a n d m ic r o s p o r id io s is , w h ic h is tr a n s m it t e d v ia in s e c ts , fis h ,
la b o r a to r y ro d e n ts , and f u r - b e a r in g a n im a ls am ong o th e rs .
I m m u n o c o m p r o m is e d in d iv id u a ls a n d t h o s e w h o w o r k c lo s e ly w it h a n im a ls a r e
a t r is k o f d e v e lo p in g z o o n o t ic in fe c tio n .
T o x o p la s m o s is is c a u s e d b y a n in t r a c e llu la r p a r a s ite , Toxoplasma gondii,
w h o s e s e x u a l life c y c le t a k e s p la c e in t h e s m a ll in te s tin e o f c a ts . In fe c tio n is
c o m m o n ly a c q u ir e d b y in g e s t in g u n d e r c o o k e d o r r a w m e a t a n d o t h e r fo o d
m a te r ia ls c o n t a in in g c y s t s a n d o o c y s ts fr o m in fe c te d c a ts . T. gondii is n o t
k n o w n to s p r e a d fr o m p e r s o n - t o - p e r s o n e x c e p t f o r t r a n s p la c e n t a l in fe c tio n
fr o m in fe c te d m o t h e r t o fe tu s (c o n g e n ita l t o x o p la s m o s is ), a n d r a r e ly b y
b lo o d t r a n s f u s io n o r b y o r g a n tr a n s p la n t a t io n . T. gondii a ls o c a u s e s
o p p o r t u n is t ic in fe c tio n in im m u n o c o m p r o m is e d in d iv id u a ls , e .g . , H IV /A ID S
p a tie n ts .
T o x o p la s m o s is m a n if e s t s th r o u g h o u t t h e b o d y , b u t m o s t c o m m o n ly a f f e c t s th e
c e n tr a l n e r v o u s s y s te m ( C N S ) a n d e y e s w h e r e it le a d s t o n e c r o tiz in g
e n c e p h a lit is a n d c h o r io r e tin itis , r e s p e c tiv e ly . O t h e r o c u la r m a n ife s ta tio n s
in c lu d e b lu r r e d v is io n , v is u a l flo a te r s , p h o to p h o b ia , e p ip h o r a , m a c u la r
in v o lv e m e n t, a n d lo s s o f c e n tr a l v is io n (o c u la r t o x o p la s m o s is ) P u lm o n a r y
to x o p la s m o s is u s u a lly o c c u rs in an im m u n o c o m p r o m is e d in d iv id u a l.
S y m p t o m s in c lu d e s h o r t n e s s o f b r e a th , fe v e r , a n d c o u g h .
T h e tr e a t m e n t o f c h o ic e f o r t o x o p la s m o s is is p y r im e t h a m in e a n d s u lfa d ia z in e
a lo n g w it h le u c o v o r in ( to s a f e g u a r d a g a in s t b o n e m a r r o w to x ic ity ) o r
p y r im e t h a m in e and c lin d a m y c in w ith le u c o v o r in .
T r im e t h o p r im / s u lf a m e t h o x a z o le is a lo w - c o s t a lt e r n a tiv e .
p a ra s ite s 96

H e lm in th s a r e th e la r g e s t in te r n a l h u m a n p a ra s ite .
H e lm in th s r e p r o d u c e s e x u a lly , g e n e r a tin g m illio n s o f e g g s o r la rv a e .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • both statem ents are true
W o rm (h e lm in th ic ) in fe c tio n s a re v e ry c o m m o n in d e v e lo p in g c o u n tr ie s . H e lm in th s a re
th e la rg e s t in te rn a l h u m a n p a ra s ite . N e m a to d e s (ro u n d w o rm s ) a n d tr e m a to d e s (flu k e s )
h a v e a m o u th a n d in te s tin a l tra c t, w h ile c e s to d e s (ta p e w o rm s ) a b s o rb n u trie n ts d ire c tly
th ro u g h th e o u te r te g u m e n t.
Nem atodes ( ro u n d w o rm s ) h u m a n in fe c tio n s ca n b e d iv id e d in to :
• Tissue-dw elling w o r m s in c lu d in g th e fila r ia l w o rm s , a n d th e G u in e a w o rm
D r a c u n c u lu s m e d in e n s is
• Hum an intestinal w o rm s , in c lu d in g th e h u m a n hookworm s, th e c o m m o n
roundworm (Ascaris lumbricoides) a n d Strongyloides stercoralis, w h ic h a re th e
most com m on h e lm in th ic p a r a s ite s o f m a n
• Zoonotic n e m a to d e s w h ic h a c c id e n ta lly in fe c t m a n a n d a re n o t a b le to c o m p le te
th e ir n o rm a l life c y c le . T h e y ty p ic a lly b e c o m e “tr a p p e d " in th e tis s u e s , c a u s in g a
p o te n tia lly s e v e re lo c a l in fla m m a to r y re s p o n s e
Trem atodes (flu k e s ) a re fla t le a f-s h a p e d w o rm s .
• Blood flukes - th e re a re th re e s p e c ie s of schistosom e w h ic h c o m m o n ly c a u s e
d is e a s e ( S c h is to s o m ia s is ) in m a n ; Schistosoma mansoni, S. haematobium, a n d
S. japonicum
• Lung flukes - th e m a jo r s p e c ie s o f Paragonim us is P. westermani w h ic h liv e s in
th e lu n g s c a u s in g P a r a g o n im ia s is . . .
• Intestinal/hepatic flukes - th e hum an liv e r flu k e s , Clonorchis sinensis,
Opisthorchis felineus, a n d O. viverrini c a u s e in fe c tio n th a t is o fte n a s y m p to m a tic
Cestodes (ta p e w o rm s ) a re rib b o n -s h a p e d w o rm s .
• Intestinal adult w orm s - Taenia saginata ( b e e f ta p e w o rm ), Taenia solium (p o rk
ta p e w o r m ) , Diphyllobothrium latum ( fis h ta p e w o rm )
A n infestation is th e p re s e n c e o f p a r a s ite s on th e b o d y (e .g ., tic k s , m ite s , a n d lic e ) o r
in th e o rg a n s (e .g ., n e m a to d e s o r w o rm s ). In fe c tio n s c a u s e d b y c e rta in n e m a to d e s
c a u s e m arked eosinophilia ( a b n o r m a lly la rg e n u m b e rs of e o s in o p h ils in th e b lo o d ).
E o s in o p h ils d o n o t in g e s t th e p a ra s ite s ; ra th e r, they attach to th e s u rfa c e o f th e
p a ra s ite s v ia Ig E a n d s e c re te c y to to x ic e n z y m e s c o n ta in e d w ith in th e ir eosinophilic
granules.
k id n e y d is e a s e 97

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith a d u lt

p o ly c y s tic k id n e y d is e a s e (A P K D ).

• a u to s o m a l d o m in a n t
• s h r u n k e n k id n e y s
• c o r tic o m e d u lla r y c y s ts
• la r g e m u lt ic y s tic k id n e y s
• liv e r c y s ts
• h e p a tic fib r o s is

M IC R O B IO L O G Y /P A T H O L O G Y t^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a u to s o m a l d o m in a n t
la r g e m u lt ic y s t ic k id n e y s
• liv e r c y s ts
S u m m a r y o f R e n a l C y s t i c D is c }

I n h e ri ta n c e P a th o lo g ic F e a tu re s C lin ic a l F e a tu r e s o r T y p ic a l O u tc o m e
C o m p lic a tio n s

A d u lt p o ly c y s tic A u to s o m a l L a rg e m u ltic y s tic H e m a tu r ia , f la n k p a in , C h r o n ic r e n a l fa ilu re

k id u c y d is e a s e d o m in a n t k id n e y s , liv e r c y s ts , u r in a r y tr a c t in f e c tio n , b e g in n in g a t a g e 4 0 -6 0
b e rry an eu ry sm s r e n a l s to n e s , h y p e rte n s io n y e ars

C h ild h o o d p o ly c y s tic A u to s o m a l E n la rg e d , c y s tic k id n e y s H e p a tic fib ro s is V a r i a b l e , d e a t h in

k id n e y d is e a s e re c e ssiv e a t b irth in f a n c y o r c h ild h o o d

M e d u lla ry sp o n g e N one M e d u lla ry c y s ts o n H e m a tu ria , u r in a r y tra c t B e n ig n

k id n e y e x c re to ry u r o g ra p h y in f e c tio n , r e c u rre n t re n a l
s to n e s

F a m ilia l ju v e n ile n e p h - A u to s o m a l C o rtic o m e d u lla ry c y s ts , S a lt w a s tin g , p o ly u r ia , P r o g r e s s iv e r e n a l f a ilu re

ro n o p h th is is re c e ssiv e s h r u n k e n k id n e y s g ro w th re ta rd a tio n , b e g in n in g in c h ild h o o d

a n e m ia

A d u lt-o n s e t m e d u lla ry A u to s o m a l C o rtic o m e d u lla ry c y s ts , S a lt w a s tin g , p o ly u r ia C h r o n ic r e n a l fa ilu re

c y s tic d is e a s e d o m in a n t s h ru n k e n k id n e y s b e g in n in g in a d u lth o o d

S im p le c y s ts N one S in g le o r m u ltip le c y s ts M ic r o s c o p ic h e m a tu ria B e n ig n

in n o r m a l - s i /e d k id n e y s

A c q u ire d r e n a l c y s tic N one C y s t i c d e g e n e r a t i o n in H em o rrh a g e , D e p e n d e n c e o n d ia ly s is

d is e a s e e n d -s ta g e k id n e y d is e a s e c ry th r o c y to s is , n e o p la s ia

N o te : A d u lt p o ly c y s t ic k id n e y d is e a s e ( A P K D ) is b y f a r th e m o s t c o m m o n
in h e r it e d n e p h r o p a t h y ( p r e v a la n c e r a t e r a n g in g f r o m 1 :4 0 0 to 1 :1 0 0 0 in
C a u c a s ia n p o p u la tio n s ) .
k id n e y d is e a s e 98

M a lig n a n t h y p e r te n s io n c a n a d v e r s e ly a ffe c t a ll th e m a jo r o rg a n
s y s te m s .
T h e m o s t s u s c e p tib le o rg a n is /a re th e :

• in te s tin e s
• lu n g s
• h e a rt
• b r a in
• k id n e y s

M IC R O B IO L O G Y /P A T H O L O G Y t* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • kidneys
M alignant hypertension is a ra re b u t v e r y s e rio u s fo rm o f h ig h b lo o d p re s s u re th a t, if
le ft u n tre a te d , u s u a lly le a d s to d e a th in 3 to 6 m o n th s . T h e kidneys a re e s p e c ia lly
s e n s itiv e to in c r e a s e s in b lo o d p r e s s u re a n d p e r m a n e n t k id n e y d a m a g e is a c o m m o n
c o m p lic a tio n o f u n tr e a te d m a lig n a n t h y p e r te n s io n . L ik e h ig h b lo o d p r e s s u r e in g e n e ra l,
th e e x a c t c a u s e o f m a lig n a n t h y p e r te n s io n is n o t c o m p le te ly u n d e rs to o d .
N ephrosclerosis is a k id n e y d is o r d e r in w h ic h th e s m a lle s t a r te r ie s in th e k id n e y s ,
c a lle d th e a rte rio le s , a re d a m a g e d . T h e r e a re 3 types o f n e p h r o s c le r o s is :
1. Arterial: a tr o p h y a n d s c a rrin g o f th e k id n e y d u e to arterio sclero tic th ic k e n in g s o f
th e w a lls o f la rg e b r a n c h e s o f th e re n a l a rte ry .
2. Arteriolar: re n a l c h a n g e s a s s o c ia te d w ith hypertension in w h ic h th e a r te r io le s
th ic k e n a n d th e a r e a s th e y s u p p ly u n d e rg o is c h e m ic a tr o p h y a n d in te rs titia l
fib r o s is .
3. M alignant: ra p id d e te r io r a tio n o f re n a l fu n c tio n c a u s e d b y in fla m m a tio n o f re n a l
a rte rio le s . T h is ty p e accom panies m a lig n a n t h y p e rte n s io n .
Pyelonephritis is a n ascending urinary tract infection ( u s u a lly E. coli) th a t h a s
re a c h e d th e p e lv is of th e k id n e y . T h e r e a re two form s o f p y e lo n e p h ritis :
1. Acute, w h ic h is a n a c tiv e in fe c tio n o f th e re n a l p e lv is . T h e p e lv is m a y b e c o m e
in fla m e d a n d fille d w ith p u s.
2. In chronic cases, e x te n s iv e scar tissu e is fo r m e d in th e k id n e y , a n d re n a l fa ilu r e
b e c o m e s a p o s s ib ility .
Rem em ber: C hronic hypertension le a d s to re a c tiv e c h a n g e s in th e s m a lle r a rte rie s
a n d a r te rio le s th r o u g h o u t th e b o d y , c o lle c tiv e ly r e fe rre d to a s arteriosclerosis.
• Benign arteriosclerosis: T h is c o n d itio n r e fle c ts m ild c h r o n ic h y p e r te n s io n , a n d th e
m a jo r c h a n g e is a v a r ia b le in c r e a s e in th e a r te r ia l w a lls . “ H y a lin e ” re fe rs to th e
g la s s y a p p e a ra n c e o f th e v e s s e l w a lls c a u s e d b y th e d e p o s itio n o f p la s m a
p ro te in s .
• M alignant arteriosclerosis: E le v a te d b lo o d p r e s s u re re s u lts in ra p id ly p ro g re s s iv e
v a s c u la r d is e a s e , w ith th e o n s e t of s y m p to m a tic d is e a s e in th e b ra in , h e a rt, o r
k id n e y .
k id n e y d is e a s e 99

N e p h r o lith ia s is (re n a l s to n e s ) is m a n if e s te d b y s e v e r e s p a s m s o f p ain

(re n a l c o lic ) a n d h e m a tu r ia , o fte n w ith r e c u r r e n t s to n e fo r m a tio n .
T h e m o s t c o m m o n ly o c c u r r in g fo rm o f n e p h r o lith ia s is is s tr u v it e
s to n e s .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e fir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
* * * C a lc iu m s to n e s a c c o u n t f o r 8 0 - 9 0 % o f k id n e y s to n e s . T h e y a r e c o m p o s e d
o f c a lc iu m o x a la te , c a lc iu m p h o s p h a te , o r b o th .
N e p h r o lith ia s is is a n o t h e r n a m e f o r k id n e y s to n e s . K id n e y s to n e s a r e a ls o
c a lle d r e n a l c a lc u li. S to n e s in o t h e r p a r ts o f t h e u r in a r y s y s te m a r e c a lle d
u r in a r y c a lc u li. B o th a r e r o c k - lik e p ie c e s t h a t a r e a b o u t th e s iz e o f a g r a in o f
s a n d . T h e y fo r m m o s t o ft e n in t h e k id n e y s a n d g e t s tu c k in t h e u r e te r . T h is
b lo c k s t h e f lo w o f u r in e a n d c a u s e s r e n a l c o lic ( c h a r a c te r iz e d b y s e v e r e p a in
in t h e b a c k , lo w e r a b d o m e n , a n d g r o in o n t h e s id e o f t h e b lo c k a g e ) .
C o m p lic a t io n s m a y in c lu d e o b s t r u c t io n o f t h e u r e te r , a c u t e o r c h r o n ic
p y e lo n e p h r itis , a n d h y d r o n e p h r o s is .
T h e f o r m a t io n o f a s to n e w ith in t h e u r in a r y t r a c t r e p r e s e n ts a p o te n t ia l
c o m p lic a tio n o f m a n y d if f e r e n t d is e a s e s . In g e n e r a l, r e n a l s to n e s a r e
c o m p o s e d o f c a lc iu m s a lts , u ric a c id , c y s tin e o r s tr u v ite d e p e n d in g u p o n
th e m a jo r e t io lo g ic e n t ity . E a c h ty p e o f s to n e h a s its o w n g r o u p o f c a u s e s s o
t h a t m a n a g e m e n t o f e a c h e n tity is s p e c if ic . H o w e v e r , a ll f o u r ty p e s o f r e n a l
s t o n e s s h a r e a c o m m o n p a t h o g e n e s is t h a t is b a s e d e s s e n t ia lly u p o n
e x c e s s iv e s u p e r s a tu r a tio n o f th e u r in e w it h a p o o r ly s o lu b le m a te r ia l. R e n a l
s t o n e s g r o w u p o n t h e s u r f a c e s o f th e p a p illa e , b e c o m e d e t a c h e d a n d
a c c o m p a n y t h e u r in e a s it t r a v e ls t h e c o lle c t in g s y s te m . S in c e m a n y o f t h e s e
s to n e s a r e to o la r g e t o n e g o tia te t h e n a r r o w c o n d u it s o f t h e c o lle c t in g s y s te m ,
th e y o b s t r u c t t h e f lo w o f u r in e a n d o fte n c a u s e s e v e r e p a in .
R e n a l c a lc u li a r e m o r e c o m m o n in m e n t h a n in w o m e n a n d r a r e ly o c c u r in
c h ild r e n . T h e exact cause is unknow n. P r e d is p o s in g fa c to rs in c lu d e :
d e h y d r a tio n , in fe c tio n , c h a n g e s in u r in e p H , o b s tr u c tio n o f u r in e flo w ,
im m o b iliz a t io n c a u s in g bone r e a b s o r p tio n , m e t a b o lic fa c to r s , s u c h as
h y p e r p a r a th y r o id is m ( le a d s t o h y p e r c a lc e m ia ) , r e n a l a c id o s is , e le v a te d u ric
a c id , a n d d e fe c tiv e o x a la te m e ta b o lis m .
k id n e y d is e a s e 100

C a u s e s o f h y d r o n e p h r o s is in c lu d e e a c h o f th e fo llo w in g E X C E P T o n e .
W h ic h o n e is th e E X C E P T IO N ?

• n e p h r o lith ia s is
• a b lo o d c lo t
• a tu m o r in o r a r o u n d th e u r e te r
• a b a c te r ia l in fe c tio n

• p re g n a n c y

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a bacterial infection
H y d r o n e p h r o s is d e v e lo p s w h e n th e p e lv is a n d c a ly c e s (u rin e c o lle c tin g s tr u c tu r e s ) of
th e k id n e y s b e c o m e d is te n d e d b e c a u s e u rin e is u n a b le to d ra in fr o m th e k id n e y d o w n
th e u re te rs in to th e b la d d e r. H y d r o n e p h r o s is is not a specific disease, b u t a s ig n of
an u n d e rly in g p ro b le m .
Causes include:
• B lo c k a g e o f th e u r in a r y s y s te m (p r e s e n t • A tu m o r in o r a ro u n d th e u re te r
a t b irth - c o n g e n ita l) • P ro s ta te g la n d e n la r g e m e n t ( b e n ig n
• A k id n e y o r u re te ra l s to n e p r o s ta tic h y p e rp la s ia ). T h is c o n d itio n
( n e p h r o lith ia s is ) is n o t m a lig n a n t o r in fla m m a to r y b u t
• A b lo o d c lo t is u s u a lly p r o g r e s s iv e a n d m a y le a d
• S c a rrin g o f th e u re te r, u s u a lly fro m to o b s tr u c tio n o f th e u re th ra
in ju ry , ra d ia tio n th e r a p y o r p re v io u s • P re g n a n c y
s u rg e ry
1. O th e r d is o rd e rs th a t are associated w ith u rin a ry o u tflo w o b s tru c tio n :
° Urolithiasis: u rin a ry c a lc u lu s , fo rm e d in a n y p a rt o f th e u r in a r y tra c t.
C a lc iu m s to n e s a c c o u n t fo r 8 0 % to 9 0 % o f u r in a r y s to n e s . T h e y a re
c o m p o s e d o f c a lc iu m o x a la te o r c a lc iu m p h o s p h a te o r b o th . T h e y a re
a s s o c ia te d w ith gout, hypercalcem ia, renal infection, and
hyperparathyroidism .
° Pyelonephritis: a b a c te r ia l in fe c tio n (u s u a lly E. coli) o f th e k id n e y a n d
th e d u c ts th a t c a rry u rin e a w a y fro m th e k id n e y (u re te rs ).
P y e lo n e p h r itis m o s t o fte n o c c u r s a s a re s u lt o f u r in a r y tra c t in fe c tio n ,
p a r tic u la r ly in th e p re s e n c e o f o c c a s io n a l o r p e r s is te n t b a c k flo w of
u rin e fro m th e b la d d e r in to th e u re te rs o r k id n e y p e lv is (v e s ic o u re te ric
re flu x ). A bscesses often develop. In chronic cases, e x te n s iv e scar
tissue is fo r m e d in th e k id n e y , a n d re n a l fa ilu r e b e c o m e s a p o s s ib ility .
2. K id n e y in fe c tio n s a re u s u a lly c a u s e d b y m ic r o o r g a n is m s ascending fro m
th e lo w e r u r in a r y tra c t. M o re c o m m o n in w o m e n th a n m e n d u e to le n g th of
u rin a ry tra c t.
k id n e y d is e a s e 101

N e p h r o tic s y n d r o m e (N S ), a g lo m e r u la r d is e a s e is c h a r a c te r iz e d b y a ll
o f th e fo llo w in g E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• h e a v y p r o t e in u r ia
• lip id u r ia

• h y p e r a lb u m in e m ia
• h y p e r lip id e m ia
• s e v e re e d e m a

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • h y p e r a lb u m in e m ia
N e p h r o tic s y n d r o m e ( N S ) is a c o n d it io n c h a r a c t e r iz e d b y m a r k e d p r o te in u r ia ,
h y p o a lb u m in e m ia , h y p e r lip id e m ia , a n d e d e m a . T h e s e s y m p t o m s r e s u lt fr o m
in c r e a s e d p e r m e a b ilit y o f th e g lo m e r u la r c a p illa r ie s . A lt h o u g h N S is n o t a
d is e a s e it s e lf , it r e s u lts fr o m a s p e c if ic g lo m e r u la r d e f e c t a n d in d ic a t e s r e n a l
d a m a g e . D is e a s e s t h a t c a n c a u s e n e p h r o t ic s y n d r o m e in c lu d e a m y lo id o s is ,
c a n c e r , d ia b e t e s , H IV , g lo m e r u lo p a t h ie s , le u k e m ia , ly m p h o m a s , m u ltip le
m y e lo m a a n d S L E . N o te : A b o u t 7 5 % o f th e c a s e s o f N S r e s u lt f r o m p r im a r y
( id io p a th ic ) g lo m e r u lo n e p h r itis .
T h e d o m in a n t c lin ic a l fe a t u r e o f N S is m ild to s e v e r e d e p e n d e n t e d e m a o f
th e a n k le s o r s a c r u m , o r p e r io r b ita l e d e m a , e s p e c ia lly in c h ild r e n . E d e m a
m a y le a d t o a s c it e s , p le u r a l e ff u s io n , a n d s w o lle n e x te r n a l g e n ita lia . E a r ly
s y m p t o m s in c lu d e lo s s o f a p p e tite , a g e n e r a l s ic k f e e lin g , p u ff y e y e lid s ,
a b d o m in a l p a in , w a s t in g o f m u s c le s , t is s u e s w e llin g f r o m e x c e s s s a lt a n d
w a t e r r e te n tio n , a n d f r o t h y u r in e ( h ig h p r o te in c o n te n t) .
M a jo r c o m p lic a t io n s a r e m a ln u tr itio n , in fe c tio n , c o a g u la t io n d is o r d e r s ,
th r o m b o e m b o lic v a s c u la r o c c lu s io n , a n d a c c e le r a t e d a t h e r o s c le r o s is . N S c a n
o c c u r a t a n y a g e . In c h ild r e n it is m o s t c o m m o n b e t w e e n a g e s 1 8 m o n t h s a n d
4 y e a r s , a n d m o r e b o y s t h a n g ir ls a r e a ff e c te d . In o ld e r p e o p le , th e s e x e s a r e
m o r e e q u a lly a ffe c t e d .
 The G lom erular Diseases

Syndrome Manifestations

N e p h ritic s y n d ro m e H e m a tu ria , a z o te m ia , v a ria b le p r o te in u ria , o lig u r ia , e d e m a , a n d h y p e rte n s io n

R a p id ly p ro g re s s in g A c u te n e p h ritis , p ro te in u ria , a n d a c u te re n a l fa ilu r e

g lo m e ru lo n e p h ritis

N e p h ro tic s y n d ro m e > 3 .5 g rn /d a y p r o te in u ria , h y p o a lb u m in e m ia , h y p e rlip id e m ia , lip id u r ia , s e v e re e d e m a

C h ro n ic re n a l fa ilu r e A z o te m ia - > u re m ia p ro g re s s in g fro m m o n th s to y e a rs

Is o la te d u r in a ry a b n o rm a litie s G lo m e ru la r h e m a tu ria a n d /o r s u b n e p h ro tic p ro te in u ria

1 . W B C s a r e m o r e c h a r a c te r is tic o f p y e lo n e p h r itis th a n n e p h r o tic

s y n d ro m e .
2 . W ith a n e p h r it ic s y n d r o m e R B C c a s ts ( c lu m p s ) w ill b e p r e s e n t in
th e u rin e .
3 . In fa r c tio n m ig h t le a d to th e p r e s e n c e o f a fe w R B C s in th e u rin e .
4. H y p e r lip id e m ia a s s o c ia te d w ith n e p h r o tic s y n d r o m e is s e c o n d a r y
to in c r e a s e d h e p a tic fa t s y n th e s is a n d d e c r e a s e d fa t c a ta b o lis m .
k id n e y d is e a s e 102

W h ic h o f th e fo llo w in g is th e c la s s ic p r e s e n ta tio n o f a c u te
p o s ts tr e p to c o c c a l g lo m e r u lo n e p h r it is ?

• r a p id ly p r o g r e s s in g g lo m e r u lo n e p h r it is
• n e p h r o tic s y n d r o m e
• n e p h r itic s y n d r o m e
• n e p h r o lith ia s is

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 n e p h ritic s y n d ro m e
C lin ic a l p r e s e n ta tio n s o f re n a l d is e a s e :
• N e p h ritic s y n d ro m e is d u e to g lo m e r u la r d is e a s e a n d is d o m in a te d b y th e a c u te
o n s e t o f u s u a lly g r o s s ly v is ib le h e m a tu r ia ( re d b lo o d c e lls in u rin e ), m ild to
m o d e r a te p r o te in u r ia , a n d h y p e r te n s io n ; it is th e c la s s ic p re s e n ta tio n o f a c u te
p o s ts tr e p to c o c c a l g lo m e r u lo n e p h r itis .
• R ap id ly p ro g re s s iv e g lo m e ru lo n e p h ritis is c h a r a c te r iz e d a s a n e p h r itic
s y n d ro m e w ith ra p id d e c lin e ( h o u r s to d a y s ) in G F R .
• N ep h ro tic s y n d ro m e , a ls o d u e to g lo m e ru la r d is e a s e , is c h a r a c te r iz e d b y h e a v y
p r o te in u r ia , h y p o a lb u m in e m ia , s e v e re e d e m a , h y p e r lip id e m ia , a n d lip id u r ia .
• A s y m p to m a tic h e m a tu ria o r p ro tein u ria , o r a c o m b in a tio n o f th e s e tw o , is
u s u a lly a m a n ife s ta tio n o f s u b tle o r m ild g lo m e ru la r a b n o r m a litie s .
• A cu te ren al fa ilu re is d o m in a te d b y o lig u r ia o r a n u r ia ( r e d u c e d o r n o u r in e flo w ) ,
a n d r e c e n t o n s e t o f a zo te m ia . It c a n r e s u lt fr o m g lo m e r u la r , in te r s titia l, o r
v a s c u la r in ju r y o r a c u te tu b u la r in ju ry .
• C h ro n ic ren al fa ilu re , c h a r a c te r iz e d b y p r o lo n g e d s y m p to m s a n d s ig n s of
u r e m ia , is th e e n d r e s u lt o f a ll c h r o n ic re n a l p a r e n c h y m a l d is e a s e s .
• R en al tu b u la r d e fec ts a re d o m in a te d b y p o ly u r ia , n o c tu r ia , a n d e le c tro ly te
d is o r d e r s ( e .g ., m e ta b o lic a c id o s is ) .
• U rin a ry tra c t in fe c tio n is c h a ra c te r iz e d b y b a c te r iu r ia a n d p y u r ia ( b a c te r ia a n d
le u k o c y te s in th e u r in e ) . T h e in fe c tio n m a y b e s y m p to m a tic o r a s y m p to m a tic , a n d
it m a y a ffe c t th e k id n e y ( p y e lo n e p h r itis ) o r th e b la d d e r ( c y s titis ) .
• N e p h ro lith ia s is ( re n a l s to n e s ) is m a n ife s te d b y s e v e re s p a s m s o f p a in (re n a l
c o lic ) a n d h e m a tu r ia , o fte n w ith r e c u r r e n t s to n e fo r m a tio n .
N o te: A z o te m ia is a b io c h e m ic a l a b n o r m a lity th a t re fe r s to a n e le v a tio n o f th e b lo o d
u r e a n itr o g e n (B U N ) a n d c r e a tin in e le v e ls , a n d is r e la te d la r g e ly to a d e c r e a s e d
g lo m e ru la r filtra tio n ra te ( G F R ) . A z o te m ia is a c o n s e q u e n c e o f m a n y re n a l d is o r d e r s .
W h e n a z o te m ia b e c o m e s a s s o c ia te d w ith a c o n s te lla tio n o f c lin ic a l s ig n s a n d
s y m p to m s a n d b io c h e m ic a l a b n o r m a litie s , it is te r m e d u re m ia. U r e m ia is
c h a r a c te r iz e d n o t o n ly b y fa ilu r e o f re n a l e x c r e to r y fu n c tio n b u t a ls o b y a h o s t o f
m e ta b o lic a n d e n d o c r in e a lte r a tio n s r e s u ltin g fr o m re n a l d a m a g e .
liv e r d is e a s e 103

T h e d o m in a n t in tr a h e p a tic c a u s e o f p o r ta l h y p e r te n s io n is:

• o b s tr u c tiv e th r o m b o s is
• s e v e r e r ig h t- s id e d h e a r t fa ilu r e
• c ir r h o s is
• c o n s tr ic tiv e p e r ic a r d it is

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c l< s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • cirrhosis
In c re a s e d r e s is ta n c e to p o rta l b lo o d flo w m a y d e v e lo p in a v a r ie ty o f c irc u m s ta n c e s ,
w h ic h c a n b e d iv id e d in to p r e h e p a tic , in tr a h e p a tic , a n d p o s th e p a tic c a u s e s .
• T h e m a jo r prehepatic c o n d itio n s a re o b s tr u c tiv e th r o m b o s is , n a r ro w in g of th e
p o rta l v e in b e fo re it ra m ifie s w ith in th e liv e r, o r m a s s iv e s p le n o m e g a ly w ith
in c r e a s e d s p le n ic v e in b lo o d flo w .
• T h e m a in posthepatic c a u s e s a re s e v e re r ig h t-s id e d h e a rt fa ilu r e , c o n s tric tiv e
p e ric a rd itis , a n d h e p a tic v e in o u tflo w o b s tru c tio n .
• T h e d o m in a n t intrahepatic c a u s e is c irr h o s is , a c c o u n tin g fo r m o s t c a s e s o f p o rta l
h y p e rte n s io n .
T h e p a th o p h y s io lo g y o f p o rta l h y p e rte n s io n is c o m p le x a n d in v o lv e s th e r e s is ta n c e to
p o rta l b lo o d flo w a t th e le v e l of th e s in u s o id s a n d th e in c r e a s e in p o rta l flo w c a u s e d by
h y p e r d y n a m ic c irc u la tio n .
1. A n in c r e a s e in p o rta l v e n o u s b lo o d flo w re s u ltin g fr o m a h y p e r d y n a m ic c irc u la tio n .
T h is is c a u s e d b y a rte ria l d ila tio n , p r im a r ily in th e s p la n c h n ic c irc u la tio n .
2. T h e in c r e a s e d r e s is ta n c e to p o rta l flo w a t th e le v e l o f th e s in u s o id s is c a u s e d by
c o n tra c tio n o f v a s c u la r s m o o th m u s c le c e lls a n d m y o fib r o b la s ts , a n d d is r u p tio n of
b lo o d flo w b y s c a rrin g a n d th e fo r m a tio n o f p a r e n c h y m a l n o d u le s . T h is is b y fa r th e
most common c a u s e o f p o rta l h y p e rte n s io n .
T h e fo u r m ajor clinical c o n s e q u e n c e s o f p o rta l h y p e rte n s io n a re (1) a s c ite s , (2 ) th e
fo r m a tio n o f p o r to s y s te m ic v e n o u s s h u n ts , (3 ) c o n g e s tiv e s p le n o m e g a ly , a n d (4)
h e p a tic e n c e p h a lo p a th y .
Important: O n e o f th e m o s t c o m m o n c a u s e s o f d e a th in p a tie n ts w ith c irr h o s is
w ith p o rta l h y p e rte n s io n is u p p e r G l h e m o r rh a g e fro m bleeding
a s s o c ia te d
esophageal varices. T h is c a u s e s m a s s iv e v o m itin g o f b lo o d ( h e m a te m e s is ) , re q u irin g
e m e r g e n c y tre a tm e n t to c o n tro l h e m o rrh a g e a n d p r e v e n t h y p o v o le m ic s h o c k .
1. Barrett's esophagus is a c o lu m n a r m e ta p la s ia o f th e e s o p h a g e a l
e p ith e liu m th a t o c c u r s w ith c h r o n ic re flu x .
2. Iron deficiency anem ia c a n b e a s s o c ia te d w ith e s o p h a g e a l w e b s . T h is is
c a lle d Plum m er-Vinson syndrom e a n d it is q u ite ra re .
liv e r d is e a s e 104

A s c ite s is th e a c c u m u la tio n o f e x c e s s flu id in th e p le u ra l c a v ity .

In 8 5 % o f c a s e s , a s c it e s is c a u s e d b y c ir r h o s is .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e fir s t s ta te m e n t is tr u e , t h e s e c o n d is f a ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y i t d e n t a l decks
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • t h e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e
A s c it e s is th e a c c u m u la t io n o f e x c e s s flu id in th e p e r ito n e a l c a v it y . In 8 5 % o f
c a s e s , a s c it e s is c a u s e d b y c ir r h o s is . T h e flu id is g e n e r a lly s e r o u s , h a v in g
le s s t h a n 3 g m / d L o f p r o te in ( la r g e ly a lb u m in ) , a n d a s e r u m t o a s c it e s a lb u m in
g r a d ie n t o f > 1 .1 g m /d L .
N o te : W it h lo n g - s t a n d in g a s c ite s , s e e p a g e o f p e r ito n e a l f lu id th r o u g h
t r a n s d ia p h r a g m a t ic ly m p h a t ic s m a y p r o d u c e h y d r o th o r a x , m o r e o ft e n o n th e
r ig h t s id e .
T h e p a t h o g e n e s is o f a s c it e s is c o m p le x , in v o lv in g th e fo llo w in g m e c h a n is m s :

• S in u s o id a l h y p e r t e n s io n
• P e r c o la tio n o f h e p a tic ly m p h in to th e p e r ito n e a l c a v it y
• S p la n c h n ic v a s o d ila t io n a n d h y p e r d y n a m ic c ir c u la t io n
D is o r d e r s t h a t m a y b e a s s o c ia te d w ith a s c ite s in c lu d e :
• C ir r h o s is • C o n g e s t iv e h e a r t fa ilu r e
• H e p a t it is • L iv e r c a n c e r
• P o r ta l v e in t h r o m b o s is ( c lo ts in th e • N e p h r o t ic s y n d r o m e
v e in s o f th e liv e r ) • P a n c r e a titis
• C o n s t r ic t iv e p e r ic a r d itis
_ 1. C ir r h o s is o f th e liv e r is a n e n d - s t a g e liv e r d is e a s e in w h ic h th e
n o r m a l h e p a t ic a r c h it e c t u r e is d e s t r o y e d a n d r e p la c e d b y b a n d s o f
fi b r o u s s c a r t is s u e . It is th e m o s t c o m m o n c h r o n ic liv e r d is e a s e ;
7 5 % o f c a s e s a r e c a u s e d b y a lc o h o lis m . S ig n s a n d s y m p t o m s
in c lu d e a s c ite s , s p le n o m e g a ly , s u d d e n o n s e t o f u p p e r G l b le e d in g
w it h m a s s iv e h e m a t e m e s is ( v o m itin g o f b lo o d ) , a n d ja u n d ic e .
2 . S p le n o m e g a ly in d ic a t e s p o r ta l h y p e r t e n s io n , w h ic h in t u r n c a u s e s
e s o p h a g e a l v a r ic e s . T h e s e e s o p h a g e a l v a r ic e s a r e th e m o s t
c o m m o n s o u r c e o f m a s s iv e h e m a t e m e s is in a lc o h o lic s .
3 . S p id e r a n g io m a s a r e c o m m o n in a lc o h o lic s .
liv e r d is e a s e 105

A p a tie n t w a s to ld b y h e r p h y s ic ia n th a t h e r s k in x a n th o m a s a n d
p r u r itis a re a s ig n o f c h o le s ta s is . A n o th e r lik e ly c lin ic a l m a n ife s ta tio n
o f c h o le s ta s is is:

• p r o te in u r ia

• h y p o b ilir u b in e m ia
• a lb u m in e m ia
• ja u n d ic e

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • jaundice
J a u n d ic e is a c o n d itio n p ro d u c e d w h e n e xce ss a m o u n ts of bilirubin c irc u la tin g in th e
b lo o d s tre a m d is s o lv e in th e s u b c u ta n e o u s fa t (the la y e r of fa t ju s t b e n e a th th e skin),
c a u s in g a y e llo w is h a p p e a ra n c e of th e skin a nd th e w h ite s of th e eyes. W ith th e e x c e p tio n
of p h y s io lo g ic ja u n d ic e in th e n e w b o rn (n o rm a l n e w b o rn ja u n d ic e in th e firs t w e e k of life),
all o th e r c a s e s of ja u n d ic e indica te o v e rlo a d o r d a m a g e to th e liver, o r in a b ility to m ove
b iliru b in fro m th e liv e r th ro u g h th e b ilia ry tra c t to th e gut.
Common causes of jaundice:
• In c re a s e d d e s tru c tio n of red b lo o d c e lls w ith ra p id re le a s e of b iliru b in into th e b lood
(fre e o r u n c o n ju g a te d b iliru b in )
• O b s tru c tio n of th e bile d u c ts o r d a m a g e to liv e r c e lls w h ich re s u lts in th e in a b ility of
b iliru b in to be e x c re te d in to th e G l tra c t (c o n ju g a te d )
T h e s e d e fe c ts in bile e xcre tio n p ro d u ce e le v a te d levels of conjugated o r unconjugated
b iliru b in a n d o th e r c o m p o n e n ts of b ile in th e blood. It is v e ry c o m m o n a nd is th e leading
manifestation of liver disease. It can o c c u r a t any a ge a nd in e ith e r sex.
Bilirubin is th e end p ro d u c t of h em e d e g ra d a tio n . T h e m a jo rity of d a ily p ro d u c tio n is
d e riv e d fro m b re a k d o w n of s e n e s c e n t red c e lls by th e m o n o n u c le a r p h a g o c y tic syste m ,
e sp e c ia lly in th e sp le e n , liver, a n d bo n e m a rro w . W h a te v e r th e so u rce , in tra c e llu la r h em e
o x y g e n a s e o x id iz e s h em e to b ilive rd in b u t is ra p id ly re d u ce d to free bilirubin, w h ic h is
g ra d u a lly re le a s e d from th e m a c ro p h a g e s into th e p la sm a . T h e fre e b iliru b in im m e d ia te ly
c o m b in e s s tro n g ly w ith th e plasma albumin a nd is tra n s p o rte d in th is c o m b in a tio n
th ro u g h o u t th e b lo o d a n d in te rs titia l flu id s.
W ith in h o u rs, th e fre e b iliru b in is a b s o rb e d th ro u g h th e h e p a tic c e ll m e m b ra n e . In p a ssin g
to th e in sid e s of th e h e p a tic ce lls, it is re le a se d fro m th e p la s m a a lb u m in a nd soon
th e re a fte r conjugated a b o u t 8 0 % w ith g lu c u ro n ic a c id to fo rm b iliru b in g lu c u ro n id e , a b o u t
10% w ith s u lfa te to fo rm b iliru b in su lfa te , a nd th e fin a l 10% w ith a m u ltitu d e of o th e r
s u b s ta n c e s . Important: Unconjugated bilirubin is v irtu a lly in s o lu b le in w a te r at
p h y s io lo g ic pH a n d e x is ts in tig h t c o m p le x e s w ith se ru m a lb u m in . T h is form c a n n o t be
e x c re te d in th e urine e ven w h e n blood le ve ls are high.
H igh levels of unconjugated b iliru b in in th e b lo o d s tre a m ca n c a u s e p e rm a n e n t d a m a g e
to c e rta in a re a s of th e bra in in n e w b o rn infants; th is is know n as kernicterus. T h is can
re su lt in a c h a ra c te ris tic fo rm of c rip p lin g c a lle d athetoid cerebral palsy.
liv e r d is e a s e 106

T h e m o s t c o m m o n s y m p to m o f h e p a to c e llu la r c a r c in o m a (H C C ) is:

• a b d o m in a l p a in
• c o n fu s io n
• w e ig h t lo s s
• im p o te n c e
• nausea

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a b d o m in a l p a in
H e p a to c e llu la r c a r c in o m a is o n e o f th e m o s t c o m m o n m a lig n a n c ie s w o r ld w id e ,
p r e d o m in a n tly b e c a u s e o f th e p r e v a le n c e o f c h r o n ic v ir a l h e p a titis ( h e p a titis B
a n d C ) . C h r o n ic liv e r d is e a s e o f a n y e t io lo g y is a r is k fa c to r f o r d e v e lo p m e n t o f
h e p a to c e llu la r c a r c in o m a ( H C C ) . A fla to x in s , a lc o h o l, h e m o c h r o m a to s is , a n d
a n a b o lic s te r o id s a r e o t h e r p o te n t ia l e tio lo g ic fa c to r s .
H e p a titis C is n o w a s s o c ia te d w ith H C C in n e a r ly 8 0 % o f c a s e s d ia g n o s e d in
th e U n ite d S ta te s , a n d is a lm o s t a lw a y s f o u n d in th e s e ttin g o f e s ta b lis h e d
c ir r h o s is . H e p a titis B m a y b e fr e q u e n tly a s s o c ia te d w ith H C C in th e a b s e n c e o f
c ir r h o s is .
A b d o m in a l p a in is th e m o s t c o m m o n s y m p t o m o f H C C . E x a m in a tio n m ay
r e v e a l a r ig h t u p p e r q u a d r a n t a b d o m in a l m a s s a n d /o r b r u it o v e r th e liv e r .
R e m e m b e r : P r e v io u s ly , v ir a l h e p a titis th a t w a s n o t c a u s e d b y th e ty p e A o r
ty p e B v ir u s w a s c a lle d "n o n -A , n o n -B h e p a titis .” R e c e n tly th r e e m o r e v ir u s e s
t h a t c a u s e s o m e o f th e s e n o n - A , n o n - B in f e c tio n s h a v e b e e n id e n tif ie d . T h e s e
v ir u s e s in c lu d e :
• H e p a titis C is a n R N A v ir u s w ith a n in c u b a t io n fr o m 2 to 6 w e e k s . T h is v ir u s
is a n tig e n ic a lly d iff e r e n t fr o m H e p a tit is v ir u s e s A a n d B . M o s t c a s e s o f p o s t­
tr a n s fu s io n h e p a tit is a r e o f th is ty p e . T h e d is e a s e is u s u a lly m u c h m ild e r
th a n A o r B b u t is o t h e r w is e c lin ic a lly in d is tin g u is h a b le fr o m th e m . L e a d s to
c ir r h o s is in 2 0 % to 5 0 % o f th o s e in fe c t e d , u s u a lly a ft e r a b o u t 2 0
y e a r s . Im p o r ta n t: H e p a tit is C is n o w th e m o s t c o m m o n r e a s o n fo r liv e r
tr a n s p la n ta tio n in th e U n it e d S ta te s .
• H e p a titis D is a p a r tia l R N A v ir u s a n d re q u ir e s th e p r e s e n c e o f H e p a titis
B fo r re p lic a tio n . U p to 4 0 % o f IV d r u g u s e r s a r e c o in fe c te d , b u t le s s th a n
2 % o f o th e r s w ith H e p a tit is B.
• H e p a titis E is a n R N A v ir u s t r a n s m itt e d b y c o n ta m in a te d w a t e r s u p p ly . It is
e n d e m ic in In d ia a n d p a r ts o f A s ia . T h e in c u b a t io n is 2 to 8 w e e k s . T h e
d is e a s e is g e n e r a lly m ild , a c u te a n d o fte n s u b c lin ic a l. It is r a r e ly fa ta l e x c e p t
in p r e g n a n c y , w h e n m o r ta lity c a n r e a c h 2 0 % .
liv e r d is e a s e 107

F ro m th e fo llo w in g lis t s e le c t T H R E E ite m s a s s o c ia te d w ith h e p a titis

B.

• fe c a l- o r a l r o u te o f tr a n s m is s io n
• in tr a v e n o u s d r u g a b u s e
• a n t i- H A V Ig M
• a n t i- d e lt a a g e n t a n tib o d y
• p a r e n te r a l tr a n s m is s io n
• H BsAg

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • in tra v e n o u s d ru g ab u s e
• p a re n te ra l tran s m is s io n
• H B sA g
H ep atitis A (H A V ) is a h ig h ly c o n ta g io u s in fe c tio u s d is e a s e in v o lv in g th e liv e r. It is
u s u a lly tr a n s m itte d b y th e fe c a l- o r a l ro u te . H e p a titis A u s u a lly r e s u lts fr o m in g e s tio n
o f c o n ta m in a te d fo o d , m ilk , o r w a te r . M a n y o u tb r e a k s o f th is ty p e a r e tr a c e d to
in g e s tio n o f s e a fo o d fr o m p o llu te d w a te r . 3 8 % o f th e U .S . p o p u la tio n h a v e p o s itiv e
a n tib o d ie s fo r p a s t in fe c tio n . T h e in itia l s y m p to m s (n a u s e a , v o m itin g , a n d d ia r r h e a ) o f
H e p a titis A a p p e a r a fte r a n in c u b a tio n p e r io d o f 2 - 6 w e e k s . C o m p le te re s o lu tio n
o c c u r s in a n o v e r w h e lm in g m a jo r ity o f c a s e s . N o te : A c u te d is e a s e is d ia g n o s e d b y
s e r u m a n ti-H A V IgM ; im m u n ity is c o n fe r r e d b y th e p r e s e n c e o f a n ti-H A V IgG .
H e p a titis B (H B V ) is tr a n s m itte d p a r e n te r a lly a n d b y s e x u a l c o n ta c t. It h a s an
in c u b a tio n p e r io d o f 6 w e e k s to 6 m o n th s . S y m p to m a tic d is e a s e ( e .g ., a b d o m in a l
p a in , n a u s e a , ja u n d ic e ) o c c u r s in o n ly 2 5 % o f a d u lts . 5 % o f th e U .S . p o p u la tio n h a s
s e r o lo g ic a l m a r k e r s o f p a s t in fe c tio n , w ith c h r o n ic in fe c tio n in 0 .7 % . R is k fa c to r s
in c lu d e m u ltip le s e x u a l p a r tn e r s , in trav e n o u s d ru g a b u s e , a n d r e c e ip t o f b lo o d
p r o d u c ts . M o s t p a tie n ts r e c o v e r fu lly ; h o w e v e r , s o m e d e v e lo p c h r o n ic liv e r d is e a s e .
N ote: H B s A g is th e fir s t p o s itiv e m a rk e r o f a c u te in fe c tio n . It u s u a lly d is a p p e a r s
w ith in 6 m o n th s b u t p e r s is ts in c h r o n ic d is e a s e . T h e p r e s e n c e o f a n ti-H B s A b
d e n o te s im m u n ity .

Im p o rta n t: T h e r e is no a s s o c ia tio n o f H A V w ith e ith e r c ir rh o s is o r h e p a to c e llu la r

c a r c in o m a , as th e re is fo r H e p a titis B a n d C .
1. A n in c r e a s e d s e r u m le v e l o f tra n s a m in a s e s o fte n in d ic a te s
h e p a to c e llu la r d a m a g e .
2. T h e p r e s e n c e o f s u rfac e a n tig e n (A o r B ) in a p a tie n t's s e r u m in d ic a te s
th a t th e p a tie n t is p o te n tia lly in fe c tio u s fo r H e p a titis ( c a r r ie r s ta te ).
3. H e p a titis v iru s e s a re v e r y h e a t- re s is ta n t (m o r e s o th a n th e A ID S v iru s ) .
4. P r o p e r a u to c la v in g w ill k ill th e s e v iru s e s .
liv e r d is e a s e 108

A ll o f th e fo llo w in g a re c h a r a c te r is tic s o r s e q u e la e o f c ir r h o s is
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• fib r o u s s e p ta e
• m o r e p r e v a le n t in fe m a le s
• p a r e n c h y m a l r e g e n e r a tio n
• p o r ta l h y p e r te n s io n
• h e p a to c e llu la r c a r c in o m a

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c l< s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • m o re p re v a le n t in fe m a le s
* * * T h is is false; it is tw ic e a s c o m m o n in m en a s in w o m e n .
C irr h o s is is c h a ra c te r iz e d a n a to m ic a lly b y w id e s p r e a d n o d u le s in th e liv e r c o m b in e d
w ith fib ro s is . T h e fib r o s is a n d n o d u le fo r m a tio n c a u s e s d is to r tio n o f th e n o r m a l liv e r
a r c h ite c tu r e w h ic h in te r fe r e s w ith b lo o d flo w th ro u g h th e liv e r. Im p o rta n t: C irr h o s is
is a s s o c ia te d w ith a n in c re a s e d in c id e n c e o f h e p a to c e llu la r c a r c in o m a .
A m o n g p e o p le a g e s 4 5 - 6 5 , c irr h o s is is th e th ir d m o s t c o m m o n c a u s e o f d e a th , a fte r
h e a r t d is e a s e a n d c a n c e r . C ir r h o s is o fte n h a s m a n y c o m p lic a tio n s , in c lu d in g
a c c u m u la tio n o f flu id in th e a b d o m e n (a s c ite s ) , b le e d in g d is o r d e rs ( c o a g u lo p a th y ) ,
in c r e a s e d p re s s u r e in th e b lo o d v e s s e ls (p o r ta l h y p e r te n s io n ) , a n d c o n fu s io n o r a
c h a n g e in th e le v e l o f c o n s c io u s n e s s ( h e p a tic e n c e p h a lo p a th y ) .
C au se s o f c irrh o s is:
• A lc o h o l a b u s e : m o st co m m o n c a u se • C h r o n ic c o n g e s tiv e h e a r t fa ilu r e
• C h r o n ic v ira l h e p a titis B , C , a n d D • P a r a s itic in fe c tio n s (e .g .,
• In h e r ite d m e ta b o lic d is e a s e s (e .g ., s c h is to s o m ia s is )
h e m o c h r o m a to s is , W ils o n d is e a s e ) • N o n a lc o h o lic s te a to h e p a titis ( liv e r
• C h r o n ic b ile d u c t d is e a s e s ( e .g ., in fla m m a tio n th a t c a n b e c a u s e d b y
p r im a r y b ilia r y c irr h o s is ) fa tty liv e r)
• L o n g te r m e x p o s u r e to to x in s o r
d ru g s
S ig n s o f h e p a tic fa ilu re :
• M e n w ith c ir rh o s is o f th e liv e r o fte n d e v e lo p g y n e c o m a s tia fr o m in c r e a s e d
p r o d u c tio n o f e s tr o g e n s
• F la p p in g tre m o r ( A s te r ix is ): th is tr e m o r c o m m o n ly r e s u lts fr o m liv e r fa ilu r e
• H y p o a lb u m in e m ia : lo w a lb u m in le v e l
• S p id e r te la n g ie c ta s ia s o r s p id e r a n g io m a s : s m a ll le s io n s o n th e s k in c o n ta in in g
a c e n tr a lly d ila te d , e n la r g e d , b lo o d v e s s e l fro m w h ic h s e v e r a l s m a lle r v e s s e ls
r a d ia te
lu n g d is o r d e r s 109

W h ic h ty p e o f e m p h y s e m a is a s s o c ia te d w ith a g in g a n d a lp h a ^
a n titr y p s in d e fic ie n c y ?

• p a r a s e p ta l ( d is ta l a c in a r )
• c e n tr ia c in a r ( c e n tr ilo b u la r )
• p a n a c in a r ( p a n lo b u la r )
• ir r e g u la r

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • panacinar (panlobular)
E m p h y s e m a is a c o n d itio n of th e lung c h a ra c te riz e d by irreversible enlargement of the
airspaces distal to the terminal bronchiole, a c c o m p a n ie d by d e s tru c tio n o f th e ir w a lls
w ith o u t o b v io u s fib ro s is . T h e a ir sa c s are u n a b le to c o m p le te ly d e fla te (h yp e rin fla tio n ) and
are th e re fo re u n a b le to fill w ith fre s h a ir to e n s u re a d e q u a te o x y g e n s u p p ly to th e bod y. A
pe rso n w ith e m p h y s e m a w ill have labored breathing an d an in c re a s e d s u s c e p tib ility to
in fe c tio n . T h is p e rs o n ha s tw o b a sic p ro b le m s : th e lu n g s a re “fixed” in in s p ira tio n an d th e
re s p ira to ry s u rfa c e s o f th e lu n g s h a ve deteriorated s o m u ch th a t th e y a re no lo n g e r
a d e q u a te to a c c o m p lis h n o rm a l g as e xc h a n g e .
Important: O b s tru c tio n re s u lts fro m tissue changes ra th e r th a n m u c u s p ro d u c tio n , w h ich
o c c u rs in a s th m a and c h ro n ic b ro n c h itis . T h e d is tin g u is h in g c h a ra c te ris tic of e m p h y s e m a
is a ir flo w lim ita tio n caused by lack of elastic recoil in the lungs. E m p h y s e m a also
c a u s e s an in c re a s e in lu n g compliance. C o m p lia n c e is th e v o lu m e c h a n g e p e r unit of
p re s s u re c h a n g e a cro s s an e la s tic s tru c tu re . T h e re is a c le a r-c u t a s s o c ia tio n b e tw e e n
heavy cigarette smoking an d e m p h y s e m a , and w o m e n an d A fric a n A m e ric a n s a re m ore
s u s c e p tib le th a n o th e r g ro u p s.
Four major types of emphysema:
1. Centriacinar (c e n trilo b u la r): a s s o c ia te d w ith c h ro n ic b ro n c h itis an d s m o k in g ; d e s tro y s
re s p ira to ry b ro n c h io le s ; upper lo b e s o f lu n g s m o s tly a ffe cte d . M o s t c o m m o n fo rm .
2. Panacinar (p a n lo b u la r): d e s tro y s a lv e o li an d a lv e o la r d u cts; lower lo b e s o f lu n g s
m o stly a ffe c te d ; a s s o c ia te d w ith a g in g an d a lp h a ,-a n titry p s in d e fic ie n c y .
3. Paraseptal (d ista l a cin a r): c o m m o n ly ca u s e s s p o n ta n e o u s p n e u m o th o ra x in y o u n g
a d u lts .
4. Irregular: so na m e d b e c a u s e th e a c in u s is irre g u la rly in vo lve d , is a lm o s t in v a ria b ly
a s s o c ia te d w ith sca rrin g .
1. A n a tu ra lly o c c u rrin g s u b s ta n c e in th e lu n g s c a lle d alphai-antitrypsin m ay
p ro te c t a g a in s t e m p h y s e m a . P e o p le w ith a lp h a r a n titry p s in d e fic ie n c y a re at
an in c re a s e d ris k fo r th is dise a se .
2. S y m p to m s o f e m p h y s e m a in c lu d e s h o rtn e s s of b re a th , c o u g h a nd a lim ite d
e xe rcise to le ra n ce .
3. E m p h y s e m a a n d c h ro n ic b ro n c h itis a re o fte n c lin ic a lly g ro u p e d to g e th e r a n d
re fe rre d to as c h ro n ic o b s tru c tiv e p u lm o n a ry d ise a s e (C O P D ).
lu n g d is o rd e rs 110

F o r e a c h n u m b e r e d p a th o lo g ic c h a n g e lis te d b e lo w , s e le c t th e m o s t
c lo s e ly lin k e d c lin ic a l te r m fr o m th e lis t p r o v id e d .

P a th o lo g ic C h a n g e s C lin ic a l T e r m
1. S m o o th m u s c le h y p e r p la s ia , A. E m physem a
e x c e s s m u c u s , in fla m m a tio n
B . S m a ll- a ir w a y d is e a s e , b r o n c h io litis
2 . M u c o u s g la n d h y p e r p la s ia ,
C . B r o n c h ie c ta s is
h y p e r s e c r e tio n
D . A s th m a
3 . A ir s p a c e e n la r g e m e n t, w a ll
d e s tr u c tio n E . C h r o n ic b r o n c h it is

4 . A ir w a y d ila t io n a n d s c a r r in g
5 . In fla m m a to r y s c a r r in g /o b lite r a tio n

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 1. A s th m a , 2. C h ro n ic b ro n c h itis , 3. E m p h y s e m a , 4. B ro n c h ie cta s is,
5. S m a ll-a irw a y d is e a s e , b ro n c h io litis
C O P D is c h a r a c te r iz e d b y a n in c re a s e in r e s is ta n c e to a irflo w d u e to p a rtia l o r
c o m p le te o b s tr u c tio n a t a n y le v e l, fro m th e tr a c h e a a n d la r g e r b ro n c h i to th e te rm in a l
a n d r e s p ira to r y b r o n c h io le s . In m o s t c a s e s , c h r o n ic b r o n c h itis a n d e m p h y s e m a o c c u r
to g e th e r. C h ro n ic b ro n c h itis is d e fin e d c lin ic a lly a s p e r s is te n t c o u g h w ith s p u tu m
p r o d u c tio n fo r a t le a s t 3 m o n th s in a t le a s t 2 c o n s e c u tiv e y e a rs , in th e a b s e n c e o f a n y
o th e r id e n tifia b le c a u s e . N ote: P r o te a s e s r e le a s e d fro m n e u tr o p h ils , s u c h a s
n e u tro p h il e la s ta s e a n d c a th e p s in , a n d m a trix m e ta llo p r o te in a s e s , s tim u la te th is
m u c u s h y p e rs e c re tio n .
D is o r d e r s A s s o c ia te d w i t h A i r f l o w O b s tr u c tio n : I lie S p e c t r u m o f C O I ’ D

C li n i c a l T e r m A n a to m i c S it e M a j o r P a t h o l o g ic C h a n g e s E t io lo g y S lg n s / S y m p t o m s

A s th m a B ro n ch u s S m o o th m u s c le h y p e rp la s ia , I m m u n o lo g ic a l o r E p is o d ic w h e e z in g ,
e x c e s s m u c u s , in f la m m a tio n u n d e fin e d c a u se s cou g h , dyspnea

C h r o n ic B ro n ch u s M u c o u s g la n d h y p e rp la s ia , T obacco sm oke, C o u g h , sp u tu m

b ro n c h itis h y p e rs e c r e tio n a ir p o llu ta n ts p ro d u c tio n

E m p h y sem a A c in u s A irs p u c c e n la r g e m e n t; w a ll T o b ac co sm o k e D y sp n ea
d e s tru c tio n

B r o n c h ie c ta s is B ro n ch u s A ir w a y d ila tio n a n d s c a rrin g P e rs is te n t o r C o u g h , p u ru le n t

s e v e r e in f e c t io n s s p u tu m , fe v e r

S m a ll-a ir w a y B r o n c h io le I n fla m m a to r y s c a r rin g /o b lite r a tio n T o b ac co sm oke, C o u g h , dyspnea

d is e a s e , a ir p o llu ta n ts ,
b r o n c h io litis m is c .

E m p h y s e m a a n d c h r o n ic b ro n c h itis a re o fte n c lin ic a lly g ro u p e d to g e th e r a n d re fe rre d

to a s c h ro n ic o b s tru c tiv e p u lm o n a ry d is e a s e (C O P D ), s in c e m a n y p a tie n ts h a v e
o v e r la p p in g fe a tu r e s o f d a m a g e a t b o th th e a c in a r le v e l ( e m p h y s e m a ) a n d b ro n c h ia l
le v e l ( b ro n c h itis ), a lm o s t c e r ta in ly b e c a u s e o n e e x tr in s ic fa c to r - c ig a re tte s m o k in g -
is c o m m o n to b o th . In a d d itio n , s m a ll-a irw a y d is e a s e , a v a r ia n t o f c h r o n ic b ro n c h itis ,
is n o w k n o w n to c o n tr ib u te to o b s tr u c tio n b o th in e m p h y s e m a a n d c h r o n ic b r o n c h itis .
lu n g d is o rd e rs 111

T h e m o s t c o m m o n ty p e o f a s th m a , a to p ic a s th m a , is a c la s s ic
e x a m p le of:

• t y p e I Ig E - m e d ia te d h y p e r s e n s itiv ity r e a c tio n

• ty p e II Ig E - m e d ia te d h y p e r s e n s itiv ity r e a c tio n
• t y p e III Ig E - m e d ia te d h y p e r s e n s itiv ity r e a c tio n
• t y p e IV Ig E - m e d ia te d h y p e r s e n s itiv ity r e a c tio n

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • ty p e I Ig E -m e d iate d h y p e rs e n s itiv ity reac tio n
A sthm a is a c h r o n ic in fla m m a to r y d is o r d e r o f th e a irw a y s th a t c a u s e s re c u rre n t
e p is o d e s of w h e e z in g , b r e a th le s s n e s s , c h e s t tig h tn e s s , a n d c o u g h , p a r tic u la r ly at
n ig h t a n d /o r in th e e a r ly m o rn in g s . T h e h a llm a rk s o f th e d is e a s e a re : in c re a s e d a irw a y
r e s p o n s iv e n e s s to a v a r ie ty of s tim u li, re s u ltin g in e p is o d ic b r o n c h o c o n s tr ic tio n
(b r o n c h o s p a s m ) ; in fla m m a tio n o f th e b ro n c h ia l w a lls ; a n d in c re a s e d m u c u s s e c re tio n .
A s th m a m a y b e c a te g o r iz e d in to a to p ic (e v id e n c e o f a lle rg e n s e n s itiz a tio n , o fte n in a
p a tie n t w ith a h is to ry o f a lle r g ic rh in itis , e c z e m a ) a n d n o n -a to p ic (w ith o u t e v id e n c e of
a lle rg e n s e n s itiz a tio n ). In e ith e r ty p e , e p is o d e s o f b ro n c h o s p a sm c a n b e trig g e re d by
d iv e rs e m e c h a n is m s . A s th m a m a y a ls o b e c la s s ifie d a c c o rd in g to th e a g e n ts o r e v e n ts
th a t tr ig g e r b r o n c h o c o n s tr ic tio n . T h e s e in c lu d e s e a s o n a l, e x e r c is e - in d u c e d , d ru g -
in d u c e d (e .g ., a s p irin ), a n d o c c u p a tio n a l a s th m a , a n d a s th m a tic b r o n c h itis in s m o k e rs .
Im p o rtan t: T h e re is m a rk e d e p is o d ic d y s p n e a an d w h e e z in g e x p ira tio n c a u s e d b y
n a rro w in g o f th e a irw a y s .
C h ro n ic b ro n c h itis is a v e r y c o m m o n , d e b ilita tin g re s p ira to ry d is e a s e , c h a r a c te r iz e d
b y in c re a s e d p ro d u c tio n o f m u c o u s b y th e g la n d s o f th e tra c h e a a n d b ro n c h i. T h is
c o n d itio n h a s a s tro n g a s s o c ia tio n w ith s m o k in g . C o r p u lm o n a le ( e n la r g e m e n t o f th e
rig h t v e n tr ic le o f th e h e a rt), a irw a y n a rro w in g , a n d o b s tru c tio n a lo n g w ith s q u a m o u s
m e ta p la s ia o f th e b ro n c h ia l tre e a re c o m m o n re s u lts of c h r o n ic b ro n c h itis .
R em em b er: T h e c h a ra c te ris tic p a th o lo g ic c h a n g e in c h r o n ic b r o n c h itis is
h y p e rp la s ia o f b ro n c h ia l s u b m u c o s a l g la n d s a n d b r o n c h ia l s m o o th m u s c le
h y p e rtro p h y , w h ic h c a n b e q u a n tifie d b y th e R eid ind ex, a ra tio o f g la n d u la r la y e r
th ic k n e s s to b r o n c h ia l w a ll th ic k n e s s .
Im p o rtan t: P a tie n ts w ith c h r o n ic b r o n c h itis m a y b e p re d is p o s e d to lu n g c a n c e r
(b r o n c h o g e n ic c a r c in o m a ) .
Note: A c h r o n ic lu n g a b s c e s s , T B , lo b a r p n e u m o n ia , b r o n c h o g e n ic c a rc in o m a s , a n d
p u lm o n a r y e m b o lis m a ll p re s e n t w ith a p ro d u c tiv e c o u g h (a c o u g h c o n ta in in g
s p u tu m ). T h is s p u tu m c o n ta in s m u c u s , c e llu la r d e b ris , b a c te ria , a n d m a y c o n ta in
b lo o d o r p u s .
lu n g d is o r d e r s 112

C a u s e s o f le ft-s id e d c o n g e s tiv e h e a r t fa ilu r e in c lu d e a ll o f th e

fo llo w in g E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• p u lm o n a r y e d e m a
• is c h e m ic h e a r t d is e a s e
• m itr a l r e g u r g ita tio n
• m y o c a r d itis

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • p u lm o n a r y e d e m a
P u lm o n a r y e d e m a c a n r e s u lt fr o m h e m o d y n a m ic d is tu r b a n c e s o r fr o m d ir e c t
in c r e a s e s in c a p illa r y p e r m e a b ilit y , a s a r e s u lt o f m ic r o v a s c u la r in ju r y .
The m ost com m on h e m o d y n a m ic c a u s e o f p u lm o n a r y e d e m a is in c re a s e d
h y d r o s ta tic p re s s u re , a s o c c u r s in le ft-s id e d c o n g e s tiv e h e a rt fa ilu re .
W h a te v e r th e c lin ic a l s e tt in g , p u lm o n a r y c o n g e s tio n and edem a a re
c h a r a c te r iz e d b y h e a v y , w e t lu n g s . F lu id a c c u m u la te s in it ia lly in th e b a s a l
r e g io n s o f th e lo w e r lo b e s b e c a u s e h y d r o s ta tic p r e s s u r e is g r e a te r in th e s e
s it e s .
The s e c o n d m e c h a n is m le a d in g to p u lm o n a r y e d e m a is in ju r y to th e
c a p illa r ie s o f th e a lv e o la r s e p ta . T h e e d e m a r e s u lts fr o m p r im a r y in ju r y to th e
v a s c u la r e n d o th e liu m o r d a m a g e to a lv e o la r e p ith e lia l c e lls .
T h e e a r ly s y m p to m s o f p u lm o n a r y e d e m a in c lu d e d y s p n e a , o r th o p n e a , a n d
c o u g h in g . C lin ic a l fe a tu r e s in c lu d e ta c h y c a r d ia , ta c h y p n e a , d e p e n d e n t
c r a c k le s , a n d n e c k v e in d is te n s io n . T h e tr e a t m e n t is d e s ig n e d to r e d u c e
e x tr a v a s c u la r flu id , to im p r o v e g a s e x c h a n g e a n d h e a r t fu n c tio n (i.e ., o x y g e n ,
d iu r e t ic s , v a s o p r e s s o r s , p o s it iv e in o tr o p ic a g e n ts a n d a n tia r r h y th m ic s ) .
B r o n c h ie c ta s is is a n ir r e v e r s ib le , a b n o r m a l d ila ta tio n o f th e b r o n c h i o r
b r o n c h io le s c a u s e d b y d e s tr u c tio n o f t h e ir s u p p o r tin g s tr u c tu r e s b y a c h r o n ic
n e c r o t iz in g in fe c tio n . It is c o m m o n in c h ild r e n w ith c y s tic fib r o s is . M o s t
c o m m o n s y m p t o m is a c h r o n ic , p r o d u c tiv e c o u g h w ith a f o u l-s m e llin g ,
p u r u le n t s p u tu m . R e c u r r e n t p u lm o n a r y in fe c t io n m a y le a d to lu n g a b s c e s s .
N o te : B r o n c h ie c ta s is m o s t o fte n in v o lv e s th e lo w e r lo b e s o f b o th lu n g s .
A te le c ta s is r e fe r s e ith e r to in c o m p le te e x p a n s io n o f th e lu n g s (n e o n a ta l
a te le c ta s is - w h ic h is c o m m o n in p r e m a tu r e in fa n ts d u e to ala c k o f
s u r fa c t a n t) o r to th e c o lla p s e o f p r e v io u s ly in f la te d lu n g , p r o d u c in g a r e a s o f
r e la tiv e ly a ir le s s p u lm o n a r y p a r e n c h y m a .
N o te : T h e causes and s e q u e la e of le ft s id e d c o n g e s tiv e h e a r t f a ilu r e a re
d is c u s s e d o n c a r d # 1 6 2 in th is s e r ie s .
lu n g d is o rd e rs 113

M a la b s o r p tio n o f f a t-s o lu b le v it a m in s is lik e ly in m o s t p a tie n ts w ith :

• V o n H ip p e l- L in d a u d is e a s e
• c y s tic fib r o s is
• M a r fa n 's s y n d r o m e
• fa m ilia l h y p e r c h o le s te r o le m ia

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • c y s tic fib ro s is
C y s t ic fib r o s is is a d is o r d e r o f io n tr a n s p o r t in e p ith e lia l c e lls t h a t a ff e c ts flu id
s e c r e t io n in e x o c r in e g la n d s a n d th e e p ith e lia l lin in g o f th e r e s p ir a to r y ,
g a s tr o in te s tin a l, a n d r e p r o d u c tiv e tr a c t s . It is th e m o s t c o m m o n fa ta l g e n e tic
d is e a s e in w h ite c h ild r e n . In m a n y in fa n ts , th is d is o r d e r le a d s to a b n o r m a lly
v is c o u s s e c r e tio n s , w h ic h o b s tr u c t o r g a n p a s s a g e s , r e s u ltin g in m o s t o f th e
c lin ic a l fe a tu r e s o f th is d is o r d e r , s u c h a s c h r o n ic lu n g d is e a s e s e c o n d a r y to
r e c u r r e n t in f e c tio n s , p a n c r e a tic in s u ffic ie n c y , s te a to r r h e a , m a ln u tr itio n , h e p a t ic
c ir r h o s is , in te s tin a l o b s tr u c tio n , a n d m a le in fe r t ility . T h e s e m a n ife s ta tio n s m a y
a p p e a r a t a n y p o in t in life fr o m b e fo r e b ir th to m u c h la te r in c h ild h o o d o r e v e n in
a d o le s c e n c e . Im p o r ta n t: P a tie n ts w ith c y s tic f ib r o s is o ft e n h a v e im p a ir e d
e x o c r in e p a n c r e a s fu n c t io n , r e s u ltin g in a d e fic ie n c y o f f a t-s o lu b le v ita m in s .
In n o rm a l d u c t e p ith e lia , c h lo r id e is t r a n s p o r te d b y p la s m a m e m b r a n e
c h a n n e ls ( c h lo r id e c h a n n e ls ) . T h e p r im a r y d e fe c t in c y s tic f ib r o s is r e s u lts fr o m
a b n o r m a l fu n c tio n o f a n e p ith e lia l c h lo r id e c h a n n e l p r o te in e n c o d e d b y th e c y s t ic
f ib r o s is t r a n s m e m b r a n e c o n d u c ta n c e r e g u la to r ( C F T R ) g e n e o n c h r o m o s o m e
7 q 3 1 .2.
N o te : T h e s w e a t te s t is a n im p o r ta n t d ia g n o s tic p r o c e d u r e . S e c r e tio n b y s w e a t
g la n d s o f c h lo r id e a n d s o d iu m is n o r m a l, b u t t h e ir r e a b s o r p tio n b y s w e a t d u c ts
is im p a ir e d .
V o n H ip p e l- L in d a u d is e a s e is c h a r a c t e r iz e d b y h e m a n g io m a s o f th e r e tin a
a n d th e c e r e b e llu m . A ls o a s s o c ia te d w ith c y s t s o f th e liv e r , k id n e y , a d r e n a l
g la n d s , a n d p a n c r e a s .
M a r fa n 's s y n d ro m e is a n u n c o m m o n h e r e d it a r y c o n n e c tiv e tis s u e d is o r d e r th a t
r e s u lts in a b n o r m a litie s o f th e e y e s , b o n e s , h e a r t, a n d b lo o d v e s s e ls . P a t ie n t s
a r e ta ll a n d th in w ith a b n o r m a lly lo n g le g s a n d a r m s a n d s p id e r - lik e fin g e r s .
F a m ilia l H y p e r c h o le s te r o le m ia is a g e n e t ic d e fe c t c h a r a c te r iz e d b y a n o m a lie s
of r e c e p to r s fo r lo w d e n s it y lip o p r o te in (L D L r e c e p to r s ) . Can r e s u lt in
a th e r o s c le r o s is a n d its c o m p lic a tio n s .
lu n g d is o r d e r s 114

W h ic h o f th e fo llo w in g is c a u s e d b y th e in h a la tio n o f c a r b o n d u s t?

• a s b e s to s is
• s ilic o s is

• c o a l w o r k e r s ' p n e u m o c o n io s is
• a n th r a c o s is

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a n th r a c o s is
P n e u m o c o n io s e s a re e n v ir o n m e n ta l d is e a s e s caused by p r o lo n g e d
in h a la tio n o f in o r g a n ic d u s t p a r tic le s . T h e s e d is e a s e s le a d t o fib r o s is o f th e
lu n g s . T h e m a in s y m p t o m s a r e a c h r o n ic d r y c o u g h a n d s h o r tn e s s o f
b r e a th . S p e c if ic ty p e s o f p n e u m o c o n io s e s in c lu d e :
1. A n th r a c o s is : is c a u s e d b y th e in h a la tio n o f c a r b o n d u s t. C h a r a c t e r iz e d b y
c a r b o n - c a r r y in g m a c r o p h a g e s , it r e s u lts in ir r e g u la r b la c k p a tc h e s v is ib le
o n g r o s s in s p e c tio n .
2 . C o a l w o r k e r s ' p n e u m o c o n io s is : is c a u s e d b y t h e in h a la tio n o f c o a l
d u s t, w h ic h c o n t a in s b o th c a r b o n a n d s ilic a . T w o fo r m s :
- S im p le : is m a r k e d b y c o a l m a c u le s a r o u n d t h e b r o n c h io le s . In m o s t
c a s e s , it p r o d u c e s n o d is a b ilit y .
° P r o g r e s s iv e m a s s iv e fib r o s is : is m a r k e d b y f ib r o t ic n o d u le s fille d w it h
n e c r o t ic b la c k f lu id . It c a n r e s u lt in b r o n c h ie c t a s is , p u lm o n a r y
h y p e r te n s io n o r d e a th fr o m r e s p ir a to r y f a ilu r e o r r ig h t- s id e d h e a r t fa ilu r e .
3 . S ilic o s is ( s to n e m a s o n 's d is e a s e ) : is c a u s e d b y t h e in h a la tio n o f fr e e
s ilic a d u s t. It is c h a r a c t e r iz e d b y s ilic o t ic n o d u le s t h a t e n la r g e a n d
e v e n tu a lly o b s t r u c t t h e a ir w a y s a n d b lo o d v e s s e ls . It is t h e m o s t c o m m o n
a n d m o s t s e r io u s p n e u m o c o n io s is a n d is a s s o c ia t e d w ith in c r e a s e d
s u s c e p t ib ilit y t o T B ( r e fe r r e d to a s s ilic o tu b e r c u lo s is ) .
4 . A s b e s to s is : is c a u s e d b y th e in h a la tio n o f a s b e s to s fib e r s . It le a d s to
d iffu s e in te r s tit ia l fib r o s is , m a in ly in t h e lo w e r lo b e s . It is c h a r a c t e r iz e d
b y fe r r u g in o u s b o d ie s ( y e llo w - b r o w n , r o d - s h a p e d b o d ie s t h a t s ta in w ith
P r u s s ia n b lu e ) . A s b e s t o s is r e s u lts in m a rk e d p r e d is p o s it io n to
b r o n c h o g e n ic c a r c in o m a a n d t o m a lig n a n t m e s o t h e lio m a o f t h e p le u r a
o r p e r ito n e u m .
5 . B e r y llio s is : is c a u s e d b y th e in h a la tio n o f b e r y lliu m p a r tic le s . It is a
s y s t e m ic g r a n u lo m a t o u s d is o r d e r c h a r a c t e r iz e d by n o n - c a s e a t in g
g r a n u lo m a s a n d p r im a r y p u lm o n a r y in v o lv e m e n t. It m im ic s s a r c o id o s is .
lu n g d is o r d e r s 115

In te r s tit ia l p n e u m o n ia is m o s t o fte n c a u s e d b y S tre p to c o c c u s

p n e u m o n ia e .
T h e v ir u le n c e o f th e p n e u m o c o c c u s is a s s o c ia te d w ith its c a p s u la r
p o ly s a c c h a r id e .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e fir s t s t a t e m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • th e firs t s ta te m e n t is fa ls e , th e s e c o n d is tru e
P n e u m o n ia is a n in fla m m a to r y p r o c e s s o f in fe c tio u s o rig in a ffe c tin g th e p u lm o n a ry
p a re n c h y m a . It is c h a ra c te riz e d b y c h ills a nd fe v e r, p ro d u c tiv e c o u g h , b lo o d -tin g e d o r
ru s ty s p u tu m , h y p o x ia w ith a s h o rtn e s s o f b re a th , a n d s o m e tim e s c y a n o s is .
T h e re a re 3 m o rp h o lo g ic ty p e s of p n e u m o n ia :
1 . L ob ar p neu m o n ia: is m o s t o fte n c a u s e d b y Streptococcus pneumoniae. It is
c h a ra c te riz e d b y a p r e d o m in a n tly in tra -a lv e o la r e x u d a te , w ith in fla m m a tio n a n d
c o n s o lid a tio n o f a lo b e o r e n tire lu n g . It a ffe c ts m id d le -a g e d p e rs o n s .
2. B ro n ch o p n eu m o n ia: is c a u s e d b y a w id e v a r ie ty of o r g a n is m s (i.e .,
Staphylococcus aureus, Haemophilus influenzae, Klebsiella, Streptococcus
pyogenes). It is c h a ra c te riz e d b y a p atc h y d is trib u tio n in v o lv in g o n e o r m o re
lo b e s , w ith a n in fla m m a to r y in filtra te e x te n d in g fro m th e b ro n c h io le s in to th e
a d ja c e n t a lv e o li. It a ffe c ts in fa n ts a n d th e e ld e rly .
3. in terstitial p n eu m o n ia: is c a u s e d b y v a r io u s in fe c tio u s a g e n ts , m o s t c o m m o n ly
Mycoplasma pneumoniae o r v iru s e s (i.e ., R S V , a d e n o v iru s e s ). It is c h a ra c te riz e d
b y d iffu s e , p a tc h y in fla m m a tio n lo c a liz e d to in te r s titia l a re a s o f a lv e o la r w a lls . It
a ffe c ts y o u n g c h ild re n .
C o m p lic a tio n s o f p n eu m o n ia in c lu d e (1) tis s u e d e s tr u c tio n a n d n e c ro s is c a u s in g
a b s c e s s fo r m a tio n ; (2 ) s p re a d o f in fe c tio n to th e p le u ra l c a v ity , c a u s in g th e in tra p le u ra l
fib rin o s u p p u r a tiv e re a c tio n k n o w n a s em p yem a; a n d (3) b a c te r e m ic d is s e m in a tio n to
th e h e a rt v a lv e s , p e ric a rd iu m , b ra in , k id n e y s , s p le e n , o r jo in ts , c a u s in g m e ta s ta tic
a b s c e s s e s , e n d o c a rd itis , m e n in g itis , o r s u p p u r a tiv e a rth ritis .
1. B a c te ria l p n e u m o n ia s te n d to b e th e m o s t s e rio u s . In a d u lts , b a c te r ia a re
th e m o s t c o m m o n c a u s e , a n d o f th e s e Streptococcus pneumoniae
(p n e u m o c o c c u s ) is th e m o s t c o m m o n . It is th e m o s t c o m m o n fa ta l
in fe c tio n a c q u ire d in th e h o s p ita l.
2. T h e v iru le n c e o f th e p n e u m o c o c c u s is a s s o c ia te d w ith its c a p s u la r
p o lys a cc h a rid e .
3. R e s p ira to ry v iru s e s (i.e ., in flu e n z a v iru s e s , a d e n o v iru s e s , rh in o v iru s , a n d
R S V ) a re th e m o s t c o m m o n c a u s e s o f p n e u m o n ia in y o u n g c h ild re n ,
p e a k in g b e tw e e n th e a g e s o f tw o a n d th re e .
4. C lin ic al fin d in g s in p n eu m o n ia: c r a c k le s o n a u s c u lta tio n , h y p o x ia a n d
in filtra te o n c h e s t x -ra y .
lu n g d is o rd e rs 116

W h ic h o f th e fo llo w in g a r e m o s t o fte n r e s p o n s ib le fo r lu n g
abscesses?

• p ro te u s
• k le b s ie lla
• s ta p h y lo c o c c i
• pseudom onas

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • s ta p h y lo c o c c i
T h e te r m “ p u lm o n a r y a b s c e s s ” ( lu n g a b s c e s s ) d e s c r ib e s a lo c a l s u p p u r a tiv e
p r o c e s s w it h in th e lu n g , c h a r a c t e r iz e d b y n e c r o s is o f lu n g tis s u e . A lt h o u g h
u n d e r a p p r o p r ia t e c ir c u m s t a n c e s a n y p a t h o g e n c a n p r o d u c e a n a b s c e s s , th e
c o m m o n ly is o la te d o r g a n is m s in c lu d e a e r o b ic a n d a n a e r o b ic s tr e p t o c o c c i, S .
aureus, a n d a h o s t o f g r a m - n e g a t iv e o r g a n is m s . N o te : A n a e r o b ic o r g a n is m s
n o r m a lly fo u n d in th e o r a l c a v it y , in c lu d in g m e m b e r s o f th e B a c te r o id e s ,
F u s o b a c te r iu m , a n d P e p t o c o c c u s s p e c ie s , a r e th e e x c lu s iv e is o la t e s in a b o u t
6 0 % o f ca se s.
T h e c a u s a t iv e o r g a n is m s a r e in t r o d u c e d b y m a n y m e c h a n is m s b u t t h e m o s t
f r e q u e n t is a s p ir a tio n o f in fe c tiv e ( c o n t a m in a t e d w it h m ic r o o r g a n is m s )
m a te r ia l, o ft e n in th e s e tt in g o f a lte r e d c o n s c io u s n e s s . P u lm o n a r y
a b s c e s s e s d u e to a s p ir a t io n a r e m o r e c o m m o n o n th e r ig h t ( b e c a u s e o f th e
m o r e v e r t ic a l r ig h t m a in b r o n c h u s ) a n d a r e m o s t o f te n s in g le . O th e r c a u s e s
in c lu d e : b r o n c h ia l o b s t r u c t io n ( o ft e n b y c a n c e r ) b r o n c h ie c t a s is , o r p e r h a p s b e
a c o m p lic a t io n o f b a c te r ia l p n e u m o n ia .
Im p o r ta n t: A lc o h o lis m is t h e s in g le m o s t c o m m o n c o n d it io n p r e d is p o s in g to
lu n g a b s c e s s . P e r s o n s s u f f e r in g fr o m d r u g o v e r d o s a g e , a lo n g w it h e p ile p tic s ,
a n d p a t ie n t s w it h n e u r o lo g ic d y s f u n c t io n im p a ir in g th e g a g r e fle x a r e a ls o a t
r is k .
T h e c a r d in a l h is to lo g ic c h a n g e in a ll a b s c e s s e s is s u p p u r a tiv e d e s tr u c tio n
o f th e lu n g p a r e n c h y m a w it h in th e c e n tr a l a r e a o f c a v it a tio n .
_ 1 . A lm o s t a ll p a t ie n t s w it h a lu n g a b s c e s s p r e s e n t w it h a c o u g h a n d
fe v e r .
2 . O n e o f th e m o s t c h a r a c t e r is t ic c lin ic a l m a n if e s t a t io n s is th e
p r o d u c tio n o f la r g e a m o u n t s o f a fo u l- s m e llin g , p u r u le n t s p u tu m .
3 . D y s p n e a , c h e s t p a in , a n d c y a n o s is m a y b e p r e s e n t. C h e s t x - r a y
r e v e a ls flu id - f ille d c a v ity .
n e o p la s m s 117

F ro m th e fo llo w in g lis t s e le c t th e T W O ite m s a s s o c ia te d w ith n o d u la r

m e la n o m a .

• m o s t c o m m o n t y p e o f m e la n o m a
• r a d ia l g r o w th p h a s e p r e d o m in a te s
• v e r tic a l g r o w th p h a s e p r e d o m in a te s
• H u tc h in s o n fr e c k le
• le a s t c o m m o n ty p e o f m e la n o m a
• b le e d in g o r u lc e r a tio n

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • vertical growth phase predom inates
• bleeding or ulceration
M align an t m e la n o m a invo lves th e ce lls (m e la n o cyte s) th a t p ro du ce p ig m e n t (m e lan in ), w hich is
re sp o n sib le fo r skin a nd h a ir co lo r. M e la n o m a ca n sp re a d v e ry ra p id ly a n d is th e most deadly
form o f skin ca n c e r. It is th e le a d in g c a u s e o f d e a th fro m skin d ise a se . M e la n o m a m a y a p p e a r
on n orm a l skin, o r it m a y b e g in a t a m ole (n e vus) o r o th e r a re a th a t h a s c h a n g e d in a p p e a ra n ce .
S o m e m o le s p re se n t at birth m ay d e ve lo p into m e la n o m a s. T h e d e ve lo p m e n t of m e la n o m a is
related to sun exposure, p a rticu la rly to s u n b u rn s d urin g ch ild ho od , and is m o st co m m on a m o ng
p e o p le w ith fa ir skin, blue o r g re en e yes, a n d red o r b lo n d e hair.
Growth phases:
Radial (initial p ha se)
• D e scrib e s th e h o rizo n tal sp re a d o f m e la n o m a w ith in th e e p id e rm is a nd su p e rficia l d e rm is
• L ym p h o cyte re sp o n se is p ro m in e n t
• D uring th is initial stage th e tu m o r ce lls se e m to lack the capacity to m etastasize
Vertical (la te r p h a se )
• T u m o r c e lls inva d e d o w n w a rd into th e d e e p e r d erm a l la ye rs as an e xp a n sile m ass
• P ro g n o sis v a rie s w ith th e d e p th o f in va sio n
• A p p e a ra n c e o f a n od u le a nd c o rre la te s w ith th e e m e rg e n c e o f a c lo n e o f ce lls w ith
m etastatic potential
C linical varian ts o f m align an t m elanom a:
• S uperficial spreading m e la n o m a is th e most common typ e o f m e la n o m a . It is a large flat
irre g u la rly p ig m e n ted lesion. Radial grow th phase predom inates.
• N odular m e la n o m a is th e m o st a g g re s s iv e type. It p re se n ts as a ra p id ly g ro w in g p ig m e n ted
nodule w hich ble ed s o r ulce ra te s. Vertical growth phase predom inates. Poorest
prognosis.
• Lentigo m aligna m e la n o m a o ccu rs on s u n -e x p o s e d skin. T h e radial g ro w th phase
p re d o m in a te s. M o s t o fte n d e v e lo p s fro m p re -e xistin g le n tig o m a lig n a (Hutchinson freckle).
• A cral-len tig in o u s m e la n o m a is th e least com mon fo rm o f m e la n o m a . A rise as p ig m e n te d
le sio ns on th e p alm , s o le o r u n d e r th e n ail. T h e y m ay not be related to su n e xpo sure.
n e o p la s m s 118

A ll o f th e fo llo w in g a r e c lin ic a l s y m p to m s o f a p h e o c h r o m o c y to m a
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• b r a d y c a r d ia
• h y p e r te n s io n
• headaches
• p a lp it a tio n s

• d ia p h o r e s is

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • b ra d y c a rd ia
P h e o c h r o m o c y to m a s a r e n e o p la s m s c o m p o s e d o f c h r o m a ffin c e lls , w h ic h
s y n th e s iz e a n d r e le a s e c a te c h o la m in e s a n d in s o m e in s ta n c e s p e p tid e
h o r m o n e s . It is im p o r ta n t to r e c o g n iz e th e s e t u m o r s b e c a u s e t h e y a r e a r a r e
c a u s e o f s u r g ic a lly c o r r e c ta b le h y p e r te n s io n . C a te c h o la m in e s t y p ic a lly s e c r e t e d ,
e ith e r in te r m itt e n tly o r c o n tin u o u s ly , in c lu d e n o r e p in e p h r in e a n d e p in e p h r in e
a n d r a r e ly d o p a m in e .
T r a d it io n a lly , p h e o c h r o m o c y to m a s h a v e b e e n a s s o c ia te d w ith a “ ru le o f 1 0 s ” :
• 10% o f p h e o c h r o m o c y to m a s a re e x tr a - a d r e n a l, o c c u r r in g in s it e s s u c h a s th e
o r g a n s o f Z u c k e r k a n d l a n d th e c a r o tid b o d y . P h e o c h r o m o c y to m a s th a t
d e v e lo p in e x tr a - a d r e n a l p a r a g a n g lia a r e d e s ig n a te d p a r a g a n g lio m a s .
• 10% o f s p o r a d ic a d r e n a l p h e o c h r o m o c y to m a s a r e b ila te r a l.
• 1 0 % o f a d r e n a l p h e o c h r o m o c y to m a s a re b io lo g ic a lly m a lig n a n t . M o r e
c o m m o n in e x tr a - a d r e n a l p a r a g a n g lio m a s .
• 10% o f a d r e n a l p h e o c h r o m o c y to m a s a re n o t a s s o c ia te d w it h h y p e r te n s io n .
R e m e m b e r : P h e o c h r o m o c y to m a m a y b e a p a r t o f o r a s s o c ia te d w ith M E N
( m u lt ip le e n d o c r in e n e o p la s ia ) , n e u r o fib r o m a to s is (v o n R e c k lin g h a u s e n 's
d is e a s e ) , o r v o n H ip p le - L in d a u d is e a s e ( m u lt ip le h e m a n g io m a s ) .
1. In c r e a s e d u r in a r y e x c r e tio n o f c a te c h o la m in e s a n d th e ir m e ta b o lite s
( m e t a n e p h r in e , n o r m e t a n e p h r in e , a n d v a n illy lm a n d e lic a c id ) is
c h a r a c te r is tic . It c a n a ls o c a u s e h y p e r g ly c e m ia .
2. A n e u r o b la s to m a is a h ig h ly m a lig n a n t c a t e c h o la m in e - p r o d u c in g
t u m o r o f e a r ly c h ild h o o d th a t u s u a lly o r ig in a te s in th e a d r e n a l
m e d u lla . It is th e m o s t c o m m o n m a lig n a n t tu m o r o f c h ild h o o d
a n d in fa n c y . C o m p lic a tio n s in c lu d e in v a s io n o f a b d o m in a l o r g a n s b y
d ir e c t s p r e a d a n d m e ta s ta s is to liv e r , lu n g o r b o n e . T h e fir s t
s y m p to m s in m a n y c h ild r e n in c lu d e a la r g e a b d o m e n , a s e n s a t io n
o f fu lln e s s , a n d a b d o m in a l p a in . T h is is fo llo w e d b y a n a b d o m in a l
m a s s . T h is tu m o r c a u s e s h y p e r te n s io n . O c c a s io n a lly th is t u m o r
c o n v e r t s in to a m o r e d iff e r e n tia t e d fo r m te r m e d g a n g lio n e u r o m a .
n e o p la s m s 119

W h ic h o f th e fo llo w in g a r e th e m o s t a g g r e s s iv e o f lu n g tu m o r s ,
m e ta s ta s iz e w id e ly , a n d a r e v ir tu a lly in c u r a b le b y s u r g ic a l m e a n s ?

• e p id e r m o id ( s q u a m o u s c e ll) c a r c in o m a
• a d e n o c a r c in o m a
• s m a ll c e ll ( o a t c e ll) c a r c in o m a
• la r g e c e ll ( a n a p la s t ic ) c a r c in o m a

M IC R O B IO L O G Y /P A T H O L O G Y ® * d e n ta ld e c k s
P a r i I ‘ V o lu m e 1 3 * © 2 0 1 7
 * s m a ll cell (o at c ell) c a rc in o m a
B r o n c h o g e n ic c a r c in o m a Is a m a lig n a n t n e o p la s m o f th e lu n g a ris in g fro m th e
e p ith e liu m o f th e b r o n c h u s o r b r o n c h io le .
B r o n c h o g e n ic c a r c in o m a s b e g in a s a s m a ll fo c u s o f a ty p ic a l e p ith e lia l c e lls w ith in th e
b r o n c h ia l m u c o s a . A s th e le s io n p r o g r e s s e s , th e a ty p ia b e c o m e s m a lig n a n t a n d th e
n e o p la s m g r o w s in s iz e . T h e n e o p la s m m a y g r o w in to th e b r o n c h ia l lu m e n , a lo n g th e
m u c o s a o r in to th e b r o n c h ia l w a ll a n d a d ja c e n t lu n g p a r e n c h y m a . E v e n tu a lly th e
n e o p la s m s p r e a d s to r e g io n a l lym p h n o d es a n d d is ta n t o r g a n s s u c h a s th e liver,
brain an d b o n e. M o s t b r o n c h o g e n ic c a rc in o m a s fo r m a m a s s in o r n e a r th e h ilu s .
S o m e n e o p la s m s , e s p e c ia lly th e a d en o c a rc in o m a s , fo r m a m a s s in th e p e r ip h e r y o f
th e lu n g .
M a jo r h is to lo g ic typ e s o f b r o n c h o g e n ic c a r c in o m a :
• E p id e rm o id (s q u a m o u s c ell) c a rc in o m a : m o s t a ris e in o r n e a r th e h ilu s ;
a p p e a rs a s a h ila r m a s s a n d o fte n u n d e r g o e s v e n tra l c a v ita tio n . Im p o rta n t: T h is
n e o p la s m is m o s t c o m m o n in m e n a n d is c lo s e ly related to s m o k in g .
• A d e n o c a rc in o m a : te n d to b e s m a lle r th a n o th e r b r o n c h o g e n ic c a rc in o m a s a n d
lo c a te d in th e p e rip h ery o f th e lu n g . A d is tin c tiv e ty p e o f a d e n o c a r c in o m a is
b r o n c h io lo a lv e o la r c a r c in o m a . Im p o rta n t: T h is n e o p la s m is th e m o s t c o m m o n
ty p e in w o m e n a n d n o n - s m o k e r s .
• S m a ll cell (o at c e ll) c a rc in o m a : m o s t a r is e in o r n e a r th e h ilu s ; it is th e m o st
a g g re s s iv e fo rm a n d h ig h ly m a lig n a n t. M o s t c o m m o n ly a ffe c ts m e n (8 0 % ), a n d
9 0 % o f th e m a re c ig a r e tte s m o k e r s . Im p o rta n t: T h is n e o p la s m is s tro n g ly
related to s m o kin g . It is a v e ry a g g r e s s iv e n e o p la s m , g e n e r a lly h a v in g
m e ta s ta s iz e d a t th e tim e o f d ia g n o s is . N o te: T h e o a t c e ll th a t is o b s e r v e d in th e s e
c a r c in o m a s is a s h o r t, b lu n tly s p in d le - s h a p e d , a n a p la s tic c e ll c o n ta in in g a
r e la tiv e ly la rg e , h y p e r c h r o m a tic n u c le u s w ith little o r n o c y to p la s m .
• L arg e cell (a n a p la s tic ) c a rcin o m a : c o m p o s e d o f la rg e , u n d iffe r e n tia te d
m a lig n a n t c e lls ; v a r ia b le lo c a tio n ( p e r ip h e r a l o r c e n tr a l).
N o te: W ith a ll o f th e a b o v e th e m a jo r fin d in g s a re c o u g h , w e ig h t lo s s , c h e s t p a in , a n d
dyspnea.
n e o p la s m s 120

W h ic h o f t h e fo llo w in g ly m p h o m a s u s u a lly in v o lv e s a b d o m in a l
o r g a n s a n d is c lo s e ly lin k e d to th e E p s te in -B a r r v ir u s ?

• n o n - H o d g k in 's ly m p h o m a
• H o d g k in 's ly m p h o m a
• m a n tle c e ll ly m p h o m a
• B u r k itt's ly m p h o m a
• f o llic u la r ly m p h o m a

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • B u r k it t's ly m p h o m a
N o n -H o d g k in 's L y m p h o m a s ( N H L ) a r e m a lig n a n t t u m o r s o f th e ly m p h o id
s y s t e m c la s s if ie d s e p a r a te ly fr o m H o d g k in 's ly m p h o m a . M o s t ( 7 0 % ) a r e o f B c e ll
o r ig in w ith 3 0 % o f T c e ll o rig in . T h e r e is a s lig h t m a le p r e d o m in a n c e . T h e c a u s e
is u n k n o w n . A n u m b e r o f in f e c tiv e a g e n ts a r e a s s o c ia te d w it h th e d e v e lo p m e n t
o f N H L . T h e s e in c lu d e :
• E B V v ir u s D N A • H IV in fe c tio n
• T h e h u m a n T c e ll ly m p h o tr o p h ic v ir u s • H e lic o b a c te r p y lo r i
• H e r p e s v ir u s 8
M a lig n a n t ly m p h o m a s p r e s e n t a s c ir c u m s c r ib e d s o lid t u m o r s c o m p o s e d o f c e lls
th a t a p p e a r p r im itiv e o r r e s e m b le ly m p h o c y t e s , p la s m a c e lls , o r h is tio c y te s .
U s u a lly th e fir s t in d ic a tio n o f m a lig n a n t ly m p h o m a is s w e llin g o f th e ly m p h
g la n d s , e n la r g e d to n s ils a n d a d e n o id s , a n d p a in le s s , r u b b e r y n o d e s in th e
c e r v ic a l s u p r a c la v ic u la r a r e a s . A s th e ly m p h o m a p r o g r e s s e s , th e p a tie n t
d e v e lo p s s y m p to m s s p e c if ic to th e a r e a in v o lv e d a n d s y s te m ic c o m p la in ts o f
fa tig u e , m a la is e , w e ig h t lo s s , fe v e r , a n d n ig h t s w e a ts .
Im p o r ta n t: B u r k itt's ly m p h o m a is a n a g g r e s s iv e B c e ll ly m p h o m a . T h e
A fric a n fo r m fr e q u e n tly in v o lv e s th e m a x illa o r m a n d ib le ; th e A m e r ic a n fo r m
u s u a lly in v o lv e s a b d o m in a l o r g a n s . T h e r e is a c lo s e lin k a g e to E p s te in -B a r r
V ir u s in fe c tio n ( e s p e c ia lly in th e A fr ic a n v a r ie ty ) .
_ 1. M a lig n a n t ly m p h o m a is p a th o p h y s io lo g ic a lly s im ila r to H o d g k in 's
d is e a s e , b u t R e e d -S te r n b e r g c e lls a re n o t p re s e n t, a n d th e
s p e c if ic m e c h a n is m o f ly m p h n o d e d e s t r u c tio n is d iffe r e n t.
2 . H is t o lo g ic c h a r a c te r is tic s o f m a lig n a n t ly m p h o m a in c lu d e a “s ta r ry -
s k y ” a p p e a r a n c e o f n o n - n e o p la s tic m a c r o p h a g e s .
3 . T h e r e a p p e a r s to b e a r e la t io n s h ip b e tw e e n d iff u s e ly m p h o c y tic
ly m p h o m a a n d c h r o n ic ly m p h o c y tic le u k e m ia ( C L L ) .
4. B io p s y d iffe r e n tia te s m a lig n a n t ly m p h o m a fr o m H o d g k in 's d is e a s e .
5 . E x tr a - n o d a l p r e s e n ta tio n is c o m m o n in N o n - H o d g k in 's ly m p h o m a .
n e o p la s m s 121

A ll o f th e fo llo w in g a r e p e r ip h e r a l T -c e ll a n d N K -c e ll n e o p la s m s
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• m y c o s is f u n g o id e s /s e z a r y s y n d r o m e
• la r g e g r a n u la r ly m p h o c y tic le u k e m ia
• a n a p la s tic la r g e - c e ll ly m p h o m a
• B u r k it t's ly m p h o m a

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • B u r k itt's ly m p h o m a
B u r k it t 's ly m p h o m a is a n a g g r e s s iv e B c e ll ly m p h o m a . It is a n u n c o m m o n
ly m p h o m a in th e w e s t e r n w o r ld . It is e n d e m ic to A f r ic a in t h e m o s q u it o b e lt:
th e r e is a c lo s e a s s o c ia t io n w ith th e E p s t e in - B a r r v ir u s ( E B V ) a n d it is a
d is e a s e w it h a v e r y h ig h p r o life r a tiv e in d e x w h ic h is v e r y r a p id ly fa ta l w ith o u t
th e ra p y .
T w o f o r m s o f B u r k it t 's ly m p h o m a :
• A fr ic a n fo r m is c lo s e ly a s s o c ia t e d w ith th e E B V ( 9 5 % o f c a s e s ) . A ff e c ts
c h ild r e n o f th e m id d le A f r ic a n r e g io n s . U s u a lly b e g in s a s a la r g e m a s s in
t h e ja w .
• A m e r ic a n fo r m is le s s c lo s e ly a s s o c ia t e d w it h E B V . U s u a lly b e g in s a s a n
a b d o m in a l m a s s ; t u m o r s o f th e ja w a r e r a r e .
 T h e W H O C la s s if ic a tio n o f th e

L y m p h o id N e o p la s m s

I . P r e c u r s o r B -C e ll N e o p la s m s

B -c e ll a c u te ly m p h o b la s tic le u k e m ia /ly m p h o m a (B -A L L )

II . P e r ip h e r a l B -C e ll N e o p la s m s

C h ro n ic ly m p h o c y tic le u k e m ia /s m a ll ly m p h o c y tic le u k e m ia F o llic u la r ly m p h o m a

B -c e ll p ro ly m p h o c y tic le u k e m ia M a r g in a l z o n e ly m p h o m a

L y m p h o p la s m a c y tic ly m p h o m a H a ir y c e ll ly m p h o m a

M a n tle c e ll ly m p h o m a P la s m a c y to in a /p la s m a c e ll m y e lo m a

D iff u s e la rg e B -c e ll ly m p h o m a B u rk itt ly m p h o m a

I I I . P r e c u r s o r T - C ’e l l N e o p l a s m s

T -c e ll a c u te ly m p h o b la s tic le u k e m ia /ly m p h o m a (T - A L L )

IV . P e r ip h e r a l T -C e ll a u d N K -C e ll N e o p la s m s

T -c e ll p ro ly m p h o c y tic le u k e m ia A d u lt-T -c e ll le u k e m ia /ly m p h o m a

L a r g e g ra n u la r ly m p h o c y tic le u k e m ia A n a p la s tic la rg e -c e ll ly m p h o m a

M y c o s is fim g o id e s /S e z a ry s y n d ro m e P e rip h e ra l T -c e ll ly m p h o m a , im s p e c ifie d

N K - c e ll le u k e m ia H x tra n o d a l N K /T - c e ll ly m p h o m a

V . H o d g k in L y m p h o m a

C la s s ic a l s u b ty p e s :
N o d u la r s c le r o s is
M ix e d c e llu la rity
L y m p h o c y te -ric h
L y m p h o c y te d e p le tio n

L y m p h o c y te p re d o m in a n c e
n e o p la s m s 122

In v a s io n o f th e d e r m is b y s h e e ts a n d is la n d s o f n e o p la s tic e p id e r m a l
c e lls , o fte n w ith “ k e r a tin p e a r ls ,” is c h a r a c te r is tic o f:

• s q u a m o u s c e ll c a r c in o m a
• b a s a l c e ll c a r c in o m a
• m a lig n a n t m e la n o m a
• n o d u la r m e la n o m a

• le n tig o m a lig n a m e la n o m a

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I 'V o lu m e 1 3 « © 2 0 1 7
 • s q u a m o u s c e ll c a r c in o m a
S q u a m o u s c e ll c a r c in o m a ( S C C ) is a m o r e a g g r e s s iv e t u m o r t h a n b a s a l c e ll
c a r c in o m a a s it c a n m e t a s t a s iz e if le ft u n tr e a te d . M o s t r e la te t o s u n e x p o s u r e .
S C C c a n a r is e in p r e - e x is tin g s o la r k e r a to s e s , B o w e n 's d is e a s e o r b e d u e to
c h r o n ic in f la m m a t io n s u c h a s lu p u s v u lg a r is .
C lin ic a lly , t h e le s io n s a r e o f te n k e r a to tic , r a th e r ill- d e fin e d n o d u le s w h ic h m a y
u lc e r a t e . T h e y c a n g r o w v e r y r a p id ly . E x a m in a tio n o f r e g io n a l ly m p h n o d e s is
e s s e n tia l. T h e y a r e m o s t c o m m o n o n s u n -e x p o s e d s ite s in la te r life.
U lc e r a te d le s io n s o n t h e lo w e r lip o r e a r a r e o fte n m o r e a g g r e s s iv e . S C C a r e
m o r e c o m m o n o n th e lo w e r v e r s u s u p p e r lip a n d u s u a lly d e v e lo p fr o m a
p r e c a n c e r o u s c o n d it io n r e la tin g to s u n e x p o s u r e c a lle d a c t in ic c h e ilitis .
_ 1. S C C in v o lv e s c a n c e r o u s c h a n g e s t o th e c e lls (k e r a tin o c y te s ) o f
t h e m id d le p o r tio n o f t h e e p id e r m a l s k in la y e r.
2 . S C C is a ls o a s s o c ia te d w ith c h e m ic a l c a r c in o g e n s , s u c h a s
a r s e n ic , a n d r a d ia tio n o r x - r a y e x p o s u r e .
3 . It is m o s t o f t e n lo c a lly in v a s iv e ; h o w e v e r , S C C c a n in filt r a te
u n d e r ly in g t is s u e o r m e t a s t a s iz e in ly m p h a t ic c h a n n e ls . T r e a t m e n t
c o n s is ts o f c o m p le te e x c is io n o r r a d ia tio n th e r a p y .
4 . S C C r e s e m b le s c e r v ic a l c a n c e r in h is t o lo g ic a p p e a r a n c e a n d
b io lo g ic b e h a v io r .
5 . M a lig n a n t e p ith e lia l c e lls h a v e a n in c r e a s e d n u m b e r o f la m in in
r e c e p to r s . L a m in in ( a g ly c o p r o te in ) is a m a jo r c o m p o n e n t o f
b a s e m e n t m e m b r a n e s a n d h a s n u m e r o u s b io lo g ic a l a c t iv it ie s
in c lu d in g p r o m o tio n o f c e ll a d h e s io n , m ig r a tio n , g r o w th , a n d
d iff e r e n tia tio n .
6 . S C C a c c o u n t s f o r 9 0 % o f a ll d ia g n o s e d m a lig n a n t c a n c e r s o f th e
o r a l c a v ity .
n e o p la s m s 123

B a s a l c e ll c a r c in o m a s fr e q u e n tly m e ta s ta s iz e B E C A U S E th e y a r e
lo c a lly a g g r e s s iv e a n d c a n fo r m u lc e r a tio n s a n d b le e d .

• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t a n d r e la te d
• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t b u t N O T r e la te d
• th e s ta te m e n t is c o r r e c t , b u t th e r e a s o n is N O T
• th e s ta te m e n t is N O T c o r r e c t, b u t th e r e a s o n is c o r r e c t
• n e ith e r th e s ta te m e n t N O R th e r e a s o n is c o r r e c t

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e s ta te m e n t is N O T c o r r e c t, b u t th e r e a s o n is c o r r e c t
B a s a l c e ll c a r c in o m a is t h e m o s t c o m m o n in v a s iv e c a n c e r in h u m a n s . T h e s e
a r e s lo w - g r o w in g t u m o r s th a t r a r e ly m e ta s ta s iz e . T h e y a r e d e r iv e d fr o m b a s a l
c e lls o f t h e e p id e r m is . T h e y h a v e a t e n d e n c y to o c c u r a t s u n - e x p o s e d s it e s
a n d in lig h t ly p ig m e n t e d p e o p le . T h e t u m o r is in v a s iv e , u lc e r a tiv e , o fte n
in d u r a te d , a n d lo c a lly d e s tr u c tiv e .
These tu m o rs p re s e n t c lin ic a lly a s p e a r ly p a p u le s o fte n c o n ta in in g
p r o m in e n t, d ila te d s u b e p id e r m a l b lo o d v e s s e ls ( te la n g ie c ta s ia s ) . S o m e
t u m o r s c o n ta in m e la n in a n d th u s a p p e a r s im ila r to m e la n o c y t e n e v i o r
m e la n o m a s . A d v a n c e d le s io n s m a y u lc e r a t e , a n d e x te n s iv e lo c a l in v a s io n o f
b o n e o r fa c ia l s in u s e s m a y o c c u r a f t e r m a n y y e a r s o f n e g le c t o r in u n u s u a lly
a g g r e s s iv e tu m o r s , e x p la in in g t h e a r c h a ic d e s ig n a t io n r o d e n t u lc e r s . O n e
c o m m o n a n d im p o r t a n t v a r ia n t, t h e s u p e r f ic ia l b a s a l c e ll c a r c in o m a , p r e s e n ts
a s a n e r y th e m a to u s , o c c a s io n a lly p ig m e n te d p la q u e t h a t m a y r e s e m b le e a r ly
fo rm s of m e la n o m a . The p r o g n o s is fo r B C C is good. The n e o p la s m can
u s u a lly b e c u r e d b y s u r g ic a l r e s e c tio n .
R e m e m b e r : B a s a l c e lls a r e n o r m a l s k in c e lls . T h e y m a y d e v e lo p c a n c e r o u s
c h a n g e s , c a u s in g a lu m p o r b u m p t h a t is p a in le s s . A n e w s k in g r o w t h t h a t
u lc e r a t e s , b le e d s e a s ily , o r d o e s n o t h e a l w e ll m a y in d ic a te d e v e lo p m e n t o f
b a s a l c e ll s k in c a n c e r .
Im p o r ta n t: H is to lo g ic a lly , b a s a l c e ll c a r c in o m a is c h a r a c t e r iz e d b y c lu s te r s
o f d a r k ly s t a in in g b a s a lo id c e lls w it h a ty p ic a l p a lis a d e a r r a n g e m e n t o f th e
n u c le i o f t h e c e lls a t t h e p e r ip h e r y o f t h e t u m o r c e ll c lu s te r s .
1. T h e in c id e n c e o f s k in c a n c e r h a s in c r e a s e d g r e a t ly in r e c e n t y e a r s ,
d u e in p a r t t o g r e a t e r e x p o s u r e t o U V r a d ia tio n fr o m t h e s u n .
2 . M a lig n a n t m e la n o m a is c o n s id e r e d to b e t h e m o s t s e v e r e t u m o r
o f th e s k in .
n e o p la s m s 124

W h ic h o f th e fo llo w in g p o te n tia l c a r c in o g e n s is m o s t lik e ly to p r o d u c e

fr e e r a d ic a ls ?

• a n a lk y la tin g a g e n t
• u ltr a v io le t lig h t
• a v ir u s
• io n iz in g r a d ia t io n

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • io n iz in g r a d ia tio n
A m u t a t io n is a s ta b le , h e r ita b le c h a n g e in t h e n u c le o t id e s e q u e n c e o f
g e n e t ic n u c le ic a c id (D N A ), r e s u ltin g in a n a lt e r a t io n in t h e p r o d u c t s c o d e d f o r
b y t h e g e n e . M u ta tio n s r e s u lt fr o m th r e e ty p e s o f m o le c u la r c h a n g e :
1 . B a s e s u b s tit u tio n s : o n e b a s e is in s e r te d in p la c e o f a n o th e r ; r e s u lts in
e it h e r a m is s e n s e m u ta tio n o r a n o n s e n s e m u ta tio n .
2 . F r a m e s h ift m u ta tio n : o c c u r s w h e n o n e o r m o r e b a s e p a ir s a r e a d d e d o r
d e le te d .
3 . T r a n s p o s o n s ( in s e r tio n s e q u e n c e s ) o r d e le t io n s a r e in te g r a te d in to th e
DNA.
M u t a t io n s a r e c a u s e d b y :
• C h e m ic a ls : n it r o u s o x id e a n d a lk y la tin g a g e n t s a lt e r th e e x is tin g b a s e ;
b e n z p y r e n e ( fo u n d in t o b a c c o s m o k e ) b in d s to e x is t in g D N A b a s e s a n d
c a u s e s f r a m e - s h if t m u ta tio n s .
• Io n iz in g r a d ia tio n ( g a m m a a n d x - r a y s ) : p r o d u c e f r e e r a d ic a ls t h a t c a n
a tt a c k D N A b a s e s .
• U ltr a v io le t lig h t: h a s lo w e r e n e r g y th a n x - r a y s , c a u s e s t h e c r o s s - lin k in g o f
t h e a d ja c e n t p y r im id in e b a s e s to fo r m d im e r s ( th y m in e d im e r s r e s u lt in
in a b ilit y o f t h e D N A t o r e p lic a te p r o p e r ly ) .
• V ir u s e s : b a c te r ia l v ir u s M u ( m u t a t o r b a c te r io p h a g e ) c a u s e s e it h e r fr a m e -
s h ift m u t a t io n s o r d e le tio n s .
Im p o r ta n t: C e lls w it h h ig h p r o life r a tio n a r e m o r e s e n s itiv e t o r a d ia tio n
H ig h r a d io s e n s itiv e c e lls : L o w r a d io s e n s it iv e c e lls :
• L y m p h o c y te s • N e r v e c e lls
• B o n e m a r r o w b lo o d - fo r m in g c e lls • M a t u r e b o n e c e lls
• R e p r o d u c tiv e c e lls • M u s c le c e lls
• E p it h e lia l c e lls o f G l tr a c t
n e o p la s m s 125

_ _ _ _ _ _ _ _ o f th e c o lo n is th e m o s t c o m m o n m a lig n a n c y o f th e G l tr a c t
a n d is a m a jo r c a u s e o f m o r b id ity a n d m o r ta lity w o r ld w id e .

• S a rc o m a
• A d e n o c a r c in o m a
• Lym phom a

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a d e n o c a rc in o m a
In c o n tr a s t, th e s m a ll in te s tin e , w h ic h a c c o u n ts fo r 7 5 % o f th e o v e r a ll le n g th o f th e G l
tr a c t, is a n u n c o m m o n s ite fo r b e n ig n a n d m a lig n a n t tu m o r s . A m o n g m a lig n a n t s m a ll
in te s tin a l tu m o rs , a d e n o c a r c in o m a s a n d c a r c in o id tu m o r s h a v e r o u g h ly e q u a l
in c id e n c e , fo llo w e d b y ly m p h o m a s a n d s a r c o m a s .
C o lo re c ta l a d e n o c a rc in o m a r e p r e s e n ts n e a r ly 1 5 % o f a ll c a n c e r - re la te d d e a th s in
th e U n ite d S ta te s a n d is s e c o n d o n ly to lu n g c a n c e r . C o lo r e c ta l c a n c e r (C R C )
in c id e n c e p e a k s a t 6 0 to 7 0 y e a r s o f a g e . M a le s a r e a ffe c te d s lig h tly m o re o fte n th a n
fe m a le s .
T h e r e is n o s in g le c a u s e fo r c o lo n c a n c e r . H o w e v e r , a lm o s t a ll c o lo n c a n c e r s b e g in
a s b e n ig n p o ly p s w h ic h , o v e r a p e r io d o f m a n y y e a r s , d e v e lo p in to c a n c e r s . C R C ,
w h ic h is u s u a lly a p o ly p o id m a s s w ith u lc e r a tio n , s p r e a d s b y d ir e c t in filtra tio n th r o u g h
th e b o w e l w a ll. It in v o lv e s ly m p h a tic s a n d b lo o d v e s s e ls w ith s u b s e q u e n t s p r e a d ,
m o s t c o m m o n ly to th e liv e r a n d lu n g . Im p o rta n t: C o lo r e c ta l c a n c e r is a s s o c ia te d
w ith in c r e a s e d s e r u m c o n c e n tr a tio n o f c a rc in o e m b ry o n ic a n tig e n ( C E A ) .

P re d is p o sin g fa c to rs :
• A d e n o m a to u s p o ly p s
• In h e r ite d m u ltip le p o ly p o s is s y n d ro m e s
• L o n g - s ta n d in g u lc e r a tiv e c o litis
• G e n e tic fac to rs: u p to a fo u r - fo ld in c re a s e in in c id e n c e is n o te d a m o n g re la tiv e s
o f p a tie n ts w ith c o lo n c a n c e r
• A lo w -fib e r d ie t th a t is h ig h in a n im a l fa t
_ 1. R e c ta l b le e d in g w ith e ith e r d ia r rh e a , a b d o m in a l p a in , a n d w e ig h t lo s s a re
c o m m o n s y m p to m s .
2. T h e s ig m o id c o lo n is th e m o s t c o m m o n site.
3. T u m o r s o f th e le ft s id e o f th e c o lo n ( d e s c e n d in g c o lo n ) u s u a lly c a u s e
c o n s tip a tio n /o b s tr u c tio n a n d g e n e r a lly a re d ia g n o s e d a t a n e a rlie r s ta g e
th a n tu m o r s o f th e rig h t s id e o f th e c o lo n ( a s c e n d in g c o lo n ) w h ic h
u s u a lly d o n o t o b s tr u c t e a rly .
n e o p la s m s 126

A p a tie n t h a s p r o s ta te c a n c e r . In a d d itio n to a n in c r e a s e in p ro s ta te -
s p e c ific a n tig e n , w h ic h s e r u m m a r k e r m ig h t a ls o b e e le v a te d ?

• h u m a n c h o r io n ic g o n a d o tr o p in
• a c id p h o s p h a ta s e
• c a r c in o e m b r y o n ic a n tig e n - 1 2 5
• B e n c e J o n e s p r o te in

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • a c id p h o s p h a ta s e
* * * A b io p s y c o n f ir m s th e d ia g n o s is o f p r o s ta te c a n c e r . P S A le v e ls w ill b e
e le v a te d in a ll, a n d s e r u m a c id p h o s p h a ta s e le v e ls w ill b e e le v a te d in tw o -
t h ir d s o f m e n w it h m e t a s t a t ic p r o s t a t ic c a n c e r .
P r o s ta tic c a r c in o m a a c c o u n t s f o r 7 % o f a ll c a n c e r s in m e n a n d is t h e s ix th
m o s t c o m m o n c a n c e r in th e w o r ld . M a lig n a n t c h a n g e w it h in th e p r o s ta te
b e c o m e s in c r e a s in g ly c o m m o n w it h a d v a n c in g a g e . R e m e m b e r : P r o s ta te
c a n c e r is th e m o s t c o m m o n c a n c e r in m a le s w h ile lu n g c a n c e r is t h e n u m b e r
o n e k ille r fr o m c a n c e r in b o th m e n a n d w o m e n .
M o s t p r o s t a t ic tu m o r s a r e a d e n o c a r c in o m a s t h a t a r is e in p e r ip h e r a l g la n d s ,
in v a d e t h r o u g h o u t th e p r o s ta te , a n d m a y m e ta s ta s iz e to b o n e a n d o t h e r
ti s s u e s ( lu n g s , f o r e x a m p le ) . C o m m o n la b o r a t o r y f in d in g s in c lu d e e le v a te d
le v e ls o f a c id p h o s p h a ta s e a n d p r o s ta te -s p e c ifie d a n tig e n ( P S A ) . N o te :
W ith th e a d v e n t o f P S A t e s tin g , m o s t p r o s ta te c a n c e r s a r e n o w fo u n d b e fo r e
t h e y c a u s e s y m p to m s .
P r e s e n ta tio n is u s u a lly w it h s y m p t o m s o f lo w e r u r in a r y t r a c t o b s tr u c tio n ; le s s
c o m m o n a r e s y m p t o m s o f m e t a s t a t ic s p r e a d ( e .g . b a c k p a in , w e ig h t lo s s , o r
a n e m ia ) . T h e d ia g n o s is is a ls o m a d e b y th e in c id e n ta l f in d in g o f a h a r d
ir r e g u la r g la n d o n r e c t a l e x a m in a tio n , o r a s a n u n e x p e c t e d h is to lo g ic a l r e s u lt
a f t e r p r o s t a t e c t o m y f o r w h a t w a s b e lie v e d t o b e b e n ig n p r o s ta tic h y p e r tr o p h y .
N o d u la r h y p e r p la s ia o f th e p r o s t a t e is a b e n ig n e n la r g e m e n t o f th e p r o s ta te
d u e to h y p e r p la s t ic n o d u le s o f s t r o m a a n d g la n d s d is t o r t in g th e p r o s ta te . T h is
h y p e r p la s ia c o m p r e s s e s th e u r e th r a a n d c a u s e s u r in a r y t r a c t o b s tr u c tio n .
C o m p lic a t io n s in c lu d e p y e lo n e p h r it is , h y d r o n e p h r o s is , a n d p a in f u l o r d if f ic u lt
u r in a tio n ( d y s u r ia ) . It is n o t c o n s id e r e d to b e p r e m a lig n a n t .
n e o p la s m s 127

A ll o f th e fo llo w in g a r e tr u e re g a r d in g K a p o s i s a r c o m a E X C E P T :

• it is a v a s c u la r tu m o r
• it is c a u s e d b y h e r p e s v ir u s t y p e 2
• it is h ig h ly a s s o c ia te d w it h H IV /A ID S
• it is a c la s s ic le s io n c h a r a c te r iz e d b y r e d - p u r p le p a tc h e s a n d p la q u e s th a t
e v e n tu a lly b e c o m e n o d u la r

M IC R O B IO L O G Y /P A T H O L O G Y !* d e n ta ld e c l< s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • it is c au se d by h erp e s v iru s typ e 2
K ap o si s a rc o m a (K S ) is a v a s c u la r tu m o r th a t is c a u s e d b y h u m an h erp e s v iru s 8
(H H V 8 ) o r K ap o si s a rc o m a -a s s o c ia te d h e rp e s v iru s (K S H V ). It is th e m o st
c o m m o n ly o c c u r r in g n e o p la s m in H IV /A ID S (h u m a n im m u n o d e fic ie n c y
v ir u s /a c q u ire d im m u n o d e fic ie n c y s y n d ro m e ) p a tie n ts
H H V 8 a n d a lte r e d T - c e ll im m u n ity a r e lik e ly r e s p o n s ib le fo r th e d e v e lo p m e n t of
K a p o s i s a r c o m a . T h e H H V 8 v iru s is re la te d to ly m p h o tr o p ic s u b fa m ily o f h e r p e s v ir u s
( y - h e r p e s v ir u s )
B a s e d o n p o p u la tio n d e m o g r a p h ic s a n d c lin ic a l fe a tu r e s , K aposi s a rc o m a is
c la s s ifie d in to th e fo llo w in g fo u r v a r ia n ts :
1. C las s ic K ap o si s a rc o m a is p r e v a le n t in e ld e r ly m e n o f M e d ite r r a n e a n , M id d le
E a s te rn o r E a s te rn E u ro p e a n o r ig in . It s h o w s a c lo s e a s s o c ia tio n w ith m a lig n a n c y
o r a lte r e d im m u n ity , h o w e v e r , n o t w ith H IV in fe c tio n . T h e c u ta n e o u s le s io n s o f
c la s s ic K a p o s i s a r c o m a in th e in itia l s ta g e s h o w p atch es th a t a r e r e d - p u r p le
m a c u le s c o n fin e d to th e d is ta l lo w e r e x tr e m itie s . L e s io n s fu r th e r s p r e a d
p r o x im a lly a n d tr a n s fo r m in to raised p la q u e s th a t a r e la r g e r in s iz e a n d
v io la c e o u s in h u e . L a te r o n , th e le s io n s b e c o m e n o d u la r a n d d is tin c tly n e o p la s tic .
2. E n d e m ic A frica n K ap o si s a rc o m a o c c u r s in c e r ta in H IV - s e r o n e g a tiv e
in d iv id u a ls . It c lin ic a lly r e s e m b le s c la s s ic K a p o s i s a rc o m a in a d u lts . H o w e v e r , in
c h ild r e n y o u g e r th a n 10 y e a r s o f a g e , th e c lin ic a l p ic tu r e s h o w s a n a g g r e s s iv e ,
m u ltifo c a l, ly m p h a d e n o p a th ic fo r m w ith n o c u ta n e o u s le s io n s .
3. E p id e m ic, o r A ID S -a s s o c ia te d , K ap o si s a rc o m a is m o s tly p r e v a le n t in th e
U n ite d S ta te s . It p r e s e n ts a s a n a g g re s s iv e fo r m a n d in v o lv e s th e ly m p h n o d e s
a n d s p r e a d s w id e ly to th e v is c e r a in its e a r ly c o u r s e . In c o n tr a s t to c la s s ic K a p o s i
s a r c o m a , th e le s io n s a re fo u n d n o t o n ly o n th e lo w e r e x tre m itie s , b u t a ls o o n th e
fa c e ( u s u a lly n o s e ), g e n ita lia , a n d o r a l c a v ity (p a la ta l a n d g in g iv a l).
4. T ra n s p la n t-a s s o c ia te d K ap o si s a rc o m a o c c u r s in r e c ip ie n ts o f s o lid o rg a n
tr a n s p la n ts a n d is d u e to T - c e ll im m u n o s u p p re s s io n . It a ls o p re s e n ts in
a g g r e s s iv e fo r m in v o lv in g ly m p h n o d e s , m u c o s a , a n d v is c e r a . C u ta n e o u s le s io n s
m a y o r m a y n o t b e p re s e n t.
n e o p la s m s 128

A ll o f th e fo llo w in g a r e w e ll-k n o w n c h a r a c te r is tic s o r a s s o c ia tio n s o f

b r e a s t c a n c e r E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• p o s itiv e fa m ily h is to r y
• la te m e n a r c h e
• a d ie t h ig h in a n im a l fa ts
• d e la y e d fir s t p r e g n a n c y
• o b e s ity

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c l< S
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • late m e n arc h e
B r e a s t c a n c e r is th e m o s t c o m m o n c a n c e r a ffe c tin g w o m e n a n d is th e s e c o n d m o s t
im p o r ta n t c a u s e o f d e a th ( a fte r lu n g c a n c e r ) in w o m e n a g e d 3 5 to 5 4 y e a r s . T h is
tu m o r is a lm o s t a lw a y s a n a d e n o ca rc in o m a . It is ra re b e fo r e 2 5 a n d is in c r e a s in g ly
m o r e c o m m o n w ith a g e u n til m e n o p a u s e , a t w h ic h tim e th e in c id e n c e s lo w s d o w n .
T h e s tr o n g e s t a s s o c ia tio n w ith a n in c r e a s e d r is k fo r b r e a s t c a n c e r is a fa m ily
h is to ry , s p e c ific a lly b re a s t c a n c e r in fir s t- d e g r e e r e la tiv e s ( m o th e r , s is te r , d a u g h te r ).
B r e a s t c a n c e r o c c u r s m o r e c o m m o n ly in th e left b re a s t th a n th e rig h t b r e a s t a n d
m o r e c o m m o n ly in th e o u ter u p p e r q u a d r a n t. W id e s p re a d m e ta s ta s is c a n o c c u r b y
w a y o f th e ly m p h a tic s y s te m a n d th e b lo o d s tre a m , th r o u g h th e r ig h t s id e o f th e h e a rt
a n d lu n g s , a n d e v e n tu a lly to th e o th e r b r e a s t, th e c h e s t w a ll, liv e r, b o n e , a n d b ra in .
P re d is p o sin g fa c to rs :
• P o s itiv e fa m ily h is to r y • O b e s ity
. • F irs t p r e g n a n c y a fte r 3 0
• H is to r y o f b r e a s t c a n c e r in o n e b r e a s t y e a rs a“ e ’
• E a rly m e n a r c h e a n d la te m e n o p a u s e • D ie t h ig h in a n im a l fa t
• P r o life r a tiv e fib r o c y s tic d is e a s e w ith a ty p ic a l
e p ith e lia l h y p e r p la s ia
A p ain les s m ass in th e b r e a s t is u s u a lly th e in itia l s ig n o r s y m p to m ; h o w e v e r ,
r e tra c tio n o f th e skin or n ip p le a n d peau d 'o ran g e (a s w o lle n p itte d s k in s u r fa c e )
a lo n g w ith e n la r g e m e n t o f th e a x illa r y ly m p h n o d e s m a y a ls o b e p r e s e n t. Im p o rta n t:
L y m p h n o d e in v o lv e m e n t is th e m o st v a lu a b le p ro g n o s tic p re d ic to r.
F ib ro cy s tic d is e a s e o f th e b r e a s t is th e m o s t c o m m o n c a u s e o f a c lin ic a lly p a lp a b le
b r e a s t m a s s in w o m e n 2 8 to 4 4 y e a r s o ld . S ig n s a n d s y m p to m s in c lu d e lu m p in e s s
th r o u g h o u t b o th b r e a s ts . P a in is c o m m o n , e s p e c ia lly p r io r to th e m e n s tr u a tio n p e rio d .
It is n o t m a lig n a n t, b u t m a y le a d to a n in c r e a s e d c h a n c e o f d e v e lo p in g c a r c in o m a .
N o te: A c h o rio c a rc in o m a is a r a p id ly m e ta s ta s iz in g m a lig n a n t tu m o r o f p la c e n ta l
tis s u e th a t ty p ic a lly c a u s e s p r o fu s e v a g in a l a n d in tr a - a b d o m in a l b le e d in g .
H y p e re s tro g e n is m is a m a jo r r is k fa c to r fo r th e d e v e lo p m e n t o f e n d o m e tria l
c a rcin o m a.
n e o p la s m s 129

A 5 2 -y e a r -o ld m a le w ith a 1 5 -y e a r h is to r y o f s m o k in g p r e s e n te d to th e
e m e r g e n c y d e p a r tm e n t w ith p a in a lo n g th e le ft s h o u ld e r e x te n d in g to
th e le ft a rm . O n e x a m in a tio n , p to s is w a s o b s e r v e d . H is c h e s t
r a d io g r a p h s h o w e d s o ft tis s u e o p a c ity a t th e le ft a p e x o f t h e lu n g w ith
p a rtia l d e s tr u c tio n o f fir s t a n d s e c o n d le ft p o s te r io r rib s n e a r th e
c o s to v e r te b r a l ju n c tio n . W h a t is th e m o s t lik e ly d ia g n o s is ?

• c o n s tr ic tiv e p e r ic a r d it is
• p a n c o a s t tu m o r
• b r o n c h ia l c a r c in o id
• a d e n o c a r c in o m a lu n g

M IC R O B IO L O G Y /P A T H O L O G Y @ M e n t a ld e c l< S
P a rt I - V o lu m e 13 - © 2 0 1 7
 • p a n c o a s t tu m o r
P a n c o a s t tu m o r , c o m m o n ly c a lle d s u p e r io r s u lc u s t u m o r is a t y p e o f lu n g
c a n c e r . It in v o lv e s th e s u p e r io r p u lm o n a r y s u lc u s a n d m a y s p r e a d in t o th e
b r a c h ia l p le x u s a n d c e r v ic a l s y m p a t h e t ic c h a in , c a u s in g P a n c o a s t s y n d r o m e .
D e s tr u c tio n o f th e r ib s a n d in v a s io n o f th e c h e s t w a ll a r e a ls o c o m m o n ly s e e n .
I n v o lv e m e n t o f th e s p in e , s u b c la v ia n v e s s e ls , a n d in f e r io r n e c k m a y a ls o o c c u r .
Pancoast s y n d ro m e is caused by a P ancoast tu m o r and in v o lv e s th e
fo llo w in g s ig n s a n d s y m p to m s :
1 . S h o u ld e r a n d a rm p a in a lo n g th e s u p p ly o f t h e e ig h th c e r v ic a l n e r v e tr u n k
a n d T 1 - T 2 n e r v e t r u n k s . T h e p a in m a y r a d ia te a lo n g th e u ln a r n e r v e in to
th e f o u r t h a n d fift h fi n g e r s ( C 8 ) .
2 . H o r n e r s y n d r o m e , w h ic h c o n s is t s o f p to s is , m io s is , a n d a n h id r o s is d u e
t o in filtr a tio n o f t h e P a n c o a s t t u m o r in to th e p a r a v e r t e b r a l s y m p a t h e t ic
c h a in a n d th e in f e r io r c e r v ic a l ( s te lla te ) g a n g lio n .
3 . E x te n s io n o f th e t u m o r in v o lv in g rib s a n d v e r t e b r a e t h a t m a y c a u s e s p in a l
c o m p r e s s io n a n d p a r a p le g ia .
4. A tr o p h y o f m u s c le s o r b o n e s o f th e a ff e c te d a r m .
5 . S p in a l c o m p r e s s io n a n d p a r a p le g ia m a y d e v e lo p if th e t u m o r e x te n d s
t h r o u g h th e in t e r v e r t e b r a l f o r a m in a .
n e o p la s m s 130

O fte n th e fir s t s ig n s o f lu n g c a n c e r a r e r e la te d to m e ta s ta tic s p r e a d ,

p a r tic u la r ly to th e :

• liv e r
• h e a rt
• b r a in
• th y r o id

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b ra in
L u n g c a n c e r is th e m o s t c o m m o n c a u s e o f d e a th fr o m c a n c e r in b o th m e n
a n d w o m e n . H a lf o f th e c a n c e r s a r e in o p e r a b le b y th e tim e th e p a tie n t is fir s t
s e e n in th e h o s p ita l. In v a s io n o f th e p le u r a a n d th e m e d ia s tin a l ly m p h n o d e s is
c o m m o n , a s a r e m e ta s ta s e s to th e b r a in , a d r e n a l g la n d s , liv e r , a n d b o n e s . T h e
r o u te o f m e ta s ta s is is th r o u g h th e ly m p h a tic c h a n n e ls .
B o n y m e t a s ta s e s a r e c o m m o n , g iv in g r is e to s e v e r e p a in a n d p a th o lo g ic a l
fr a c t u r e s . T h e r e is f r e q u e n t in v o lv e m e n t o f th e liv e r . S e c o n d a r y d e p o s its in th e
b r a in p r e s e n t a s a c h a n g e in p e r s o n a lity , e p ile p s y o r a s a fo c a l n e u r o lo g ic a l
le s io n . S p in a l c o r d c o m p r e s s io n is n o t u n c o m m o n a n d r e q u ir e s u r g e n t
tr e a tm e n t. S e c o n d a r y d e p o s it s in th e a d r e n a l g la n d a r e fr e q u e n tly fo u n d a t p o s t
m o r te m b u t a r e o fte n a s y m p t o m a t ic .
L u n g c a n c e r s c a n a r is e in a n y p a r t o f th e lu n g , a n d 9 0 % to 9 5 % o f c a n c e r s o f
th e lu n g a r e t h o u g h t to a r is e fr o m th e e p ith e lia l, o r lin in g c e lls o f th e la r g e r a n d
s m a lle r a ir w a y s ( b r o n c h i a n d b r o n c h io le s ) ; fo r th is r e a s o n , lu n g c a n c e r s a r e
c a lle d b r o n c h o g e n ic c a r c in o m a s . C a n c e r s c a n a ls o a r is e fr o m th e p le u r a ( th e
th in la y e r o f tis s u e t h a t s u r r o u n d s th e lu n g s ) , c a lle d m e s o th e lio m a s , o r r a r e ly
fr o m s u p p o r tin g t is s u e s w ith in th e lu n g s , fo r e x a m p le , b lo o d v e s s e ls .
P ip e a n d c ig a r s m o k in g c a n a ls o c a u s e lu n g c a n c e r , a lth o u g h th e r is k is n o t a s
h ig h a s w ith c ig a r e tt e s m o k in g . W h ile s o m e o n e w h o s m o k e s o n e p a c k o f
c ig a r e tt e s p e r d a y h a s a 2 5 t im e s h ig h e r r is k o f d e v e lo p in g lu n g c a n c e r th a n a
n o n - s m o k e r , p ip e a n d c ig a r s m o k e r s h a v e a r is k o f lu n g c a n c e r t h a t is a b o u t fiv e
tim e s t h a t o f a n o n s m o k e r .
T y p e s o f b r o n c h o g e n ic c a r c in o m a s :
• S q u a m o u s c e ll ( E p id e r m o id ) c a r c in o m a : 3 0 %
• A d e n o c a r c in o m a : 4 0 % - is n o w th e m o s t c o m m o n ty p e
• S m a ll c e ll ( o a t c e ll) : 2 0 %
• L a r g e c e ll ( a n a p la s tic ) : 10% - le a s t c o m m o n
N o te : L u n g c a n c e r a f fe c t s m a le s m o r e th a n fe m a le s (4 to 1).
n e o p la s m s 131

T h e h a llm a r k o f _ __ __ __ _ is th e p r e s e n c e o f th e c lo n a l m a lig n a n t R e e d
-S te r n b e r g c e ll in a ly m p h n o d e b io p s y o r (r a r e ly ) e x tr a n o d a l tis s u e .

• c h r o n ic ly m p h o c y tic le u k e m ia
• n o n - H o d g k in ly m p h o m a
• m u lt ip le m y e lo m a
• H o d g k in ly m p h o m a

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • Hodgkin lymphoma
H o d g k in ly m p h o m a (Hodgkin disease) is a m alignant neoplasm w ith fe a tu r e s (e .g .,
fe v e r, in fla m m a to r y c e ll in filtra te s ) re s e m b lin g a n in fla m m a to r y d is o rd e r. T h e fir s t sig n
of th is c a n c e r is o fte n a n enlarged lymph node w h ic h a p p e a rs w ith o u t a k n o w n
c a u s e . T h e d is e a s e c a n s p re a d to a d ja c e n t ly m p h n o d e s a n d la te r m a y s p re a d o u ts id e
th e ly m p h n o d e s to th e lu n g s , liv e r, b o n e s , o r b o n e m a rro w . T h e c a u s e is n o t k n o w n .
H o d g k in ly m p h o m a c h a r a c te r is tic a lly a ffe c ts y o u n g a d u lts (predom inantly young
men); a n e x c e p tio n is n o d u la r s c le ro s is , w h ic h fr e q u e n tly a ffe c ts y o u n g w o m e n .
Important: T h is n e o p la s m is c h a r a c te r iz e d in a ll fo r m s b y th e p re s e n c e o f Reed-
Sternberg cells, w h ic h a re th e a c tu a l n e o p la s tic c e lls . S y m p to m s in c lu d e a n o re x ia ,
w e ig h t lo s s , g e n e ra liz e d p ru ritu s , lo w -g ra d e fe v e r, n ig h t s w e a ts , a n e m ia , a n d
le u k o c y to s is . P ro g n o s is is m o s t fa v o r a b le w ith e a r ly d ia g n o s is a n d lim ite d
in v o lv e m e n t. L y m p h o c y te p r e d o m in a n c e is a ls o lin k e d w ith a fa v o ra b le
p ro g n o s is . Note: R e e d -S te rn b e rg c e lls a re b in u c le a te d , o r m u ltin u c le a te d , g ia n t c e lls
w ith e o s in o p h ilic in c lu s io n - lik e n u c le o li.
The different types of Hodgkin lymphoma:
• C la s s ic a l H o d g k in ly m p h o m a s :
° L y m p h o c y te - ric h : a s s o c ia tio n w ith EBV in fe c tio n ; m o re c o m m o n in men
° M ix e d c e llu la rity : a s s o c ia tio n w ith EBV in fe c tio n ; fo u n d m o s t o fte n in older
persons
- L y m p h o c y te d e p le te d : least common; a s s o c ia tio n w ith EBV in fe c tio n a n d is
a ls o m o re c o m m o n in p e r s o n s w ith HIV; poorest prognosis
° N o d u la r s c le ro s is : most common; m o re fr e q u e n tly in young women; p re s e n c e
o f lacunar cells (a R e e d -S te rn b e rg c e ll v a ria n t); p ro g n o s is is relatively good
• N o d u la r ly m p h o c y te - p r e d o m in a n t: p r o g n o s is is relatively good; n o a s s o c ia tio n
w ith E B V
1. M a n y re s e a rc h e rs b e lie v e th a t H o d g k in 's d is e a s e s ta rts a s an
in fla m m a to r y o r in fe c tio u s p ro c e s s a n d th e n b e c o m e s a n e o p la s m ; o th e rs
b e lie v e it to b e an im m u n e d is o rd e r. How ever, th e e tio lo g y o f th e d is e a s e
re m a in s a n e n ig m a .
2. N o n -H o d g k in ly m p h o m a is a m a lig n a n t ly m p h o m a c h a r a c te r iz e d b y th e
absence of Reed-Sternberg cells.
n e o p la s m s 132

A s tu d y is p e r fo r m e d to a n a ly z e c h a r a c te r is tic s o f m a lig n a n t
n e o p la s m s in b io p s y s p e c im e n s . T h e b io p s ie s w e r e p e r fo r m e d on
p a tie n ts w h o , u p o n d ig ita l re c ta l e x a m in a tio n , s h o w e d p a lp a b le m a s s
le s io n s . O f th e fo llo w in g m ic r o s c o p ic fin d in g s , w h ic h is m o s t lik e ly to
in d ic a te th a t th e n e o p la s m is m a lig n a n t?

• p le o m o r p h is m
• a ty p ia

• m e ta s ta s is
• in c r e a s e d n u c le a r /c y to p la s m ic r a tio
• n e c r o s is

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • m e ta s ta s is

C h a r a c te r is tic s o f b e n ig n a n d m a lig n a n t n e o p la s m s :
B e n ig n : M a lig n a n t:
• W e ll- d if f e r e n t ia t e d • L e s s w e ll- d if f e r e n t ia t e d ( a n a p la s tic )
• S lo w g r o w th • R a p id G r o w th
• E n c a p s u la t e d / w e ll- c ir c u m s c r ib e d • In v a s io n
• L o c a liz e d • M e ta s ta s is
• M o v a b le • I m m o v a b le
Im p o r ta n t: M e ta s ta s is is th e m ost im p o r ta n t c h a r a c t e r is t ic th a t
d is t in g u is h e s m a lig n a n t fr o m b e n ig n .
T h e d e g r e e o f lo c a liz a tio n is t h e b a s is o f s ta g in g , w h ic h is c r it ic a l to
d e te r m in e if a c u r e is lik e ly . It is t h e m o s t r e lia b le in d ic a to r o f p r o g n o s is o f
m a lig n a n t tu m o r s . A v a r ie t y o f s ta g in g t e s t s a r e u s e d t o d e t e r m in e t h e t u m o r 's
lo c a tio n , s iz e , g r o w th in to n e a r b y s tr u c tu r e s , a n d w h e t h e r o r n o t it h a s
m e ta s ta s iz e d .
N o te : A g e n e r a liz e d c la s s if ic a t io n s y s te m f o r t h e s ta g in g o f lu n g c a n c e r is th e
T M N s y s te m . In th is s y s te m , T M N r e p r e s e n ts t h e fo llo w in g :
T : T u m o r s iz e (1 = s m a lle s t t h r o u g h 4 la r g e s t) M : M e t a s t a s is (0 = a b s e n t, 1 =
p r e s e n t) N : N o d a l in v o lv e m e n t (1 th r o u g h 3 d e p e n d in g o n s e v e r it y )
n e o p la s m s 133

W h ic h o n e o f th e fo llo w in g is N O T a s s o c ia te d w ith m u lt ip le
m y e lo m a ?

• ly tic b o n e le s io n s
• B e n c e - J o n e s p r o te in
• r e n a l fa ilu r e
• h y p o c a lc e m ia
• a n e m ia

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • h yp o calcem ia
M u ltip le m y e lo m a is a plasm a cell n eo p lasm , d e riv e d fr o m B lym phocytes. It in v o lv e s
th e axial skeleton ( v e r te b r a l c o lu m n , rib s , s k u ll, p e lv is , fe m u r , c la v ic le , a n d s c a p u la ) .
B o n e le s io n s fr o m m u ltip le m y e lo m a a re th e p r im a r y c a u s e o f b o n e p a in . S in g le le s io n s
a re c a lle d plasm acytom a w h ile m u ltip le le s io n s a re te r m e d m u ltip le m yelom a. M u ltip le
m y e lo m a is a d is e a s e o f o ld er p eo p le u s u a lly o c c u r rin g a ro u n d th e a g e o f 6 5 to 7 0 y e a rs .
M ales a n d p e o p le o f A fric a n d e s c e n t a re m o re c o m m o n ly a ffe c te d .
T h e s a lie n t fe a tu r e s o f m u ltip le m y e lo m a a re a s fo llo w s :
1. It is c h a r a c te r iz e d b y lytic b one lesion s th a t a re v is ib le o n rad io g rap h as
ch aracteristic p u n ch ed -ou t areas in b o n e s , u s u a lly m e a s u r in g 1 to 4 cm in d ia m e te r.
T h e s e le s io n s b e g in in th e m e d u lla r y c a v ity o f th e b o n e a n d o fte n le a d to p a th o lo g ic
fr a c tu r e s . T h e le s io n s fu r th e r e ro d e c a n c e llo u s b o n e , d e s tr o y in g th e c o r tic a l b o n e .
2. It is a s s o c ia te d w ith b o n e pain (fro m c o m p re s s io n fr a c tu r e s o f v e rte b r a e o r rib s),
hyp ercalcem ia ( d u e to in c r e a s e d b o n e r e s o rp tio n ) , anem ia (a s in c r e a s e d p la s m a c e lls
in te rfe re w ith n o rm a l h e m a to p o ie s is ) , renal failu re (c a u s e is m u ltifa c to r ia l b u t u s u a lly
d u e to B e n c e - J o n e s p ro te in u r ia ) , azotem ia ( in c re a s e d n itr o g e n o u s w a s te p ro d u c ts
e s p e c ia lly u re a d u e to e le v a te d c e ll tu r n o v e r) , am ylo id o sis (d u e to p ro d u c tio n of
im m u n o g lo b u lin lig h t c h a in s p a r tic u la rly o f th e A6 a n d A3 fa m ilie s ), a n d recurrent
in fection s ( d u e to d e c re a s e d p r o d u c tio n o f n o r m a l Igs).
3. Oral m an ifestatio n s o f m u ltip le m y e lo m a a re d e n ta l p a in , s w e llin g , n u m b n e s s ,
e x p a n s io n o f th e ja w , a n d m o b ility o f th e te e th . T h e m an d ible is m ore com m o nly
affected th a n th e m a x illa .
L a b o r a to r y fe a tu r e s o f m u ltip le m y e lo m a a re a s fo llo w s :
1. T h e r e is u s u a lly a n in c r e a s e d le v e l o f Ig s in th e b lo o d . T h e r e m a y a ls o b e a n in c re a s e
in lig h t c h a in s k n o w n a s B en ce-Jo n es pro tein s in th e u rin e th a t c a u s e s th e u rin e to
b e c o m e fo a m y . H o w e v e r , a b s e n c e o f th e p ro te in d o e s n o t ru le o u t th e p re s e n c e of
m u ltip le m y e lo m a .
2. M o n o c lo n a l h y p e rg a m m a g lo b u lin e m ia is p r e s e n t ( re v e r s a l o f s e r u m - a lb u m in ra tio a n d
in c re a s e in to ta l s e ru m p ro te in to a le v e l o f 8 % to 16 g m % .
3. A n e m ia , h y p e rc a lc e m ia , h y p e ru ric e m ia , e le v a te d s e d im e n ta tio n ra te , a n d in c re a s e d
a lk a lin e p h o s p h a ta s e a re th e o th e r a b n o r m a litie s .
n e o p la s m s 134

W h ic h o f t h e fo llo w in g c o n ta in s r e c o g n iz a b le m a tu r e o r im m a tu r e
c e lls o r tis s u e s r e p r e s e n ta tiv e o f m o re th a n o n e g e rm c e ll la y e r a n d
s o m e tim e s a ll th r e e ?

• c a r c in o m a
• s a rc o m a
• te r a to m a
• APUDom a

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a ri I • V o lu m e 1 3 • © 2 0 1 7
 • t e r a to m a
T e r a t o m a s o r ig in a t e fr o m to tip o te n tia l c e lls s u c h a s t h o s e n o r m a lly p r e s e n t in
th e o v a r y a n d te s t is a n d s o m e t im e s a b n o r m a lly p r e s e n t in s e q u e s t e r e d m id lin e
e m b r y o n ic r e s t s . S u c h c e lls h a v e th e c a p a c it y t o d if f e r e n t ia t e in to a n y o f th e
c e ll t y p e s fo u n d in th e a d u lt b o d y a n d s o , n o t s u r p r is in g ly , m a y g iv e r is e to
n e o p la s m s t h a t m im ic , in a h e lt e r - s k e lt e r f a s h io n , b it s o f b o n e , e p ith e liu m ,
m u s c le , fa t , n e r v e , a n d o t h e r tis s u e s .
W h e n a ll th e c o m p o n e n t p a r ts a r e w e ll d if f e r e n t ia t e d , it is a b e n ig n ( m a tu r e )
t e r a to m a ; w h e n le s s w e ll d iff e r e n tia te d , it is a n im m a tu r e , p o t e n t ia lly o r o v e r tly ,
m a lig n a n t te r a t o m a . A p a r t ic u la r ly c o m m o n p a tt e r n is s e e n in t h e o v a r ia n
c y s tic t e r a t o m a ( d e r m o id c y s t) , w h ic h d if f e r e n t ia t e s p r in c ip a lly a lo n g
e c t o d e r m a l lin e s to c r e a te a c y s t ic t u m o r lin e d b y s k in r e p le te w it h h a ir,
s e b a c e o u s g la n d s , a n d to o t h s t r u c t u r e s .
A c a r c in o m a is a m a lig n a n t tu m o r of e p it h e lia l o r ig in . It o c c u r s in th e
fo llo w in g v a r ia tio n s :
• Squam ous c e ll c a r c in o m a o r ig in a t e s fr o m s t r a t if ie d squam ous
e p ith e liu m ; is m a r k e d b y t h e p r o d u c t io n o f k e r a tin
• T r a n s it io n a l c e ll c a r c in o m a a r is e s fr o m t r a n s it io n a l c e ll e p it h e liu m o f th e
u r in a r y t r a c t
• A d e n o c a r c in o m a is a c a r c in o m a o f g la n d u la r e p ith e liu m
1. A s a r c o m a is a m a lig n a n t t u m o r o f m e s e n c h y m a l o r ig in .
E x a m p le s in c lu d e : o s t e o s a r c o m a ( b o n e ) , le io m y o s a r c o m a
( s m o o th m u s c le ) , a n d lip o s a r c o m a ( a d ip o s e tis s u e ) .
2 . A n A P U D o m a is a t u m o r c h a r a c t e r iz e d b y a m in e p r e c u r s o r u p ta k e
a n d d e c a r b o x y la t io n ( A P U D ) a n d t h e r e s u lt a n t p r o d u c t io n o f
h o r m o n e - lik e s u b s ta n c e s .
n e o p la s m s 135

W h ic h o f th e fo llo w in g is a h is to lo g ic h a llm a r k o f m a lig n a n c y ?

• d y s p la s ia
• a n a p la s ia
• m e ta p la s ia
• d e s m o p la s ia

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • a n a p la s ia
D iffe r e n tia tio n is a m e a s u r e o f a tu m o r 's r e s e m b la n c e to n o rm a l tis s u e .
A n a p la s ia is th e a b s e n c e o f d iff e r e n tia t io n .
H is to lo g ic f e a tu r e s o f m a lig n a n c y :
• a n a p la s ia • h y p e r c h r o m a tis m • p le o m o r p h is m • a b n o r m a l m it o s is
T h e h o s t r e s p o n s e t o a m a lig n a n c y is b e s t r e fle c te d b y ly m p h o c y tic in filt r a tio n a t
th e e d g e o f th e tu m o r . T h e m o s t c h a r a c te r is tic fe a tu r e o f a m a lig n a n c y “ a s
o p p o s e d to a n in fla m m a to r y le s io n ” is th a t m a lig n a n c y w ill g r o w a fte r re m o v a l o f
th e c a u s a tiv e a g e n t. T h e m o s t im p o r ta n t c h a r a c te r is tic o f m a lig n a n t n e o p la s m s ,
w h ic h d is tin g u is h e s th e m fr o m b e n ig n n e o p la s m s , is th e ir a b ility t o in v a d e a n d to
m e ta s ta s iz e .
D y s p la s ia is a ty p e o f n o n m a lig n a n t c e llu la r g r o w th , b u t m a y p r e c e d e
m a lig n a n t c h a n g e s in th e tis s u e . It is a s s o c ia te d w ith c h r o n ic ir r it a tio n o f a
tis s u e b y a c h e m ic a l a g e n t, s u c h a s c ig a r e tte s m o k e , o r b y c h r o n ic
in fla m m a to r y ir r it a t io n , s u c h a s c h r o n ic c e r v ic it is . T h e tis s u e a p p e a r s s o m e w h a t
s tr u c tu r e le s s a n d d is o r g a n iz e d a n d m a y c o n s is t o f a ty p ic a l c e lls w ith o u t
in v a s io n . E p ith e liu m e x h ib it s a c a n th o s is ( a n a b n o r m a l th ic k e n in g o f th e p r ic k le
c e ll la y e r ) .
M e ta p la s ia is th e s u b s titu tio n o f o n e tis s u e n o r m a lly fo u n d a t a s it e o f a n o t h e r .
It is c o m m o n in th e lo w e r e s o p h a g u s w ith g a s t r o e s o p h a g e a l r e f lu x d is e a s e
( G E R D ) . T h e e p ith e liu m u n d e r g o e s m e ta p la s ia in r e s p o n s e t o th e o n g o in g
in fla m m a t io n fr o m r e f lu x o f g a s tr ic c o n te n ts . T h e m o s t c o m m o n ty p e o f
e p it h e lia l m e ta p la s ia in v o lv e s r e p la c e m e n t o f c o lu m n a r c e lls b y s tra tifie d
s q u a m o u s e p ith e liu m .
N e o p la s m s , a n d m a lig n a n t n e o p la s m s in p a r t ic u la r , c a n fo r m a fib r o u s s tr o m a
th a t g iv e s th e t u m o r a c h a r a c te r is tic fir m o r h a r d fe e l o n p a lp a t io n . T h is
h is to lo g ic fe a tu r e is c a lle d d e s m o p la s ia . T h is c o n n e c tiv e tis s u e c a n fix th e
tu m o r t o s u r r o u n d in g s tr u c tu r e s .
n e o p la s m s 136

A ll o f th e fo llo w in g a re b e n ig n tu m o r s o f m e s e n c h y m a l o rig in
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• o s te o g e n ic s a r c o m a
• lip o m a
• fib r o m a
• c h o n d ro m a

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • o s te o g e n ic s a r c o m a

* * * A n o s t e o g e n ic s a r c o m a is a m a l i g n a n t tu m o r o f m e s e n c h y m a l o r ig in , s p e c if ic a lly th e b o n e . It is th e m o s t
c o m m o n p r im a r y m a lig n a n t tu m o r o f b o n e .

N o m e n c la tu rc o f fi

T is s u e o f O r ig in B e n ig n M a lig n a n t

C o m p o s e d o f o n e p a re n c h y m a l c e ll ty p e

T u m o rs o f M e s e n c h y m a l O r ig in
C o n n e c tiv e tis s u e a n d d e r iv a tiv e s F ib r o m a F ib r o s a rc o m a

L ip o m a (m o s t c o m m o n s o l) tis s u e tu m o r) L ip o s a rc o m a

C h o n d ro m a C h o n d ro sa rc o m a

O s te o m a O s te o g e n ic s a r c o m a

E n d o th e lia l a n d R e la te d T is s u e s
B lo o d v e s s e ls H e m a n g io m a A n g io s a r c o ttta

L y m p h a n g io m a L y m p h a n g io s a rc o m a
L y m p h v e s s e ls
S y n o v iu m S y n o v ia l s a r c o m a

M e s o th e lim n M e s o th e lio m a

B ra in c o v e rin g s M e n in g io m a I n v a s iv e u te n ittg io trta

B lo o d C e lls a n d R e la te d C e lls
H e m a to p o ie tic c e lls L e u k e m ia s
L y m p h o m as
L y m p h o id tis s u e

M u s c le
L e io m y o m a L e io m y o s a r c o m a
S m o o th
R h ab d o m y o m a R h a b d o m y o sa rc o m a
S tr ia te d

T u m o rs o f E p ith e lia l O r ig in
S q u a m o u s c e ll p a p illo m a S q u a m o u s c e ll c a rc in o m a
S tr a tifie d s q u a m o u s
B a s a l c e ll c a rc in o m a
B a s a l c e lls o f s k in
E p ith e lia l lin in g o f g la n d s o r d u c ts A d en o m a A d e n o c a r c in o m a

P a p illo m a P a p illa ry c a rc in o m a s

C y s ta d e n o m a C y s ta d e n o c a rc in o m a s

R e s p ira to iy p a s s a g e s
R e n a l e p ith e liu m
L iv e r c e lls
U r in a ry tra c t e p ith e liu m
B ro n c h ia l a d e n o m a B ro n c h o g e n ic c a rc in o m a
R e n a l tu b u la r- a d e n o m a R e n a l c e ll c a rc in o m a
L iv e r c e ll a d e n o m a H e p a to c e lh r la r c a rc in o m a
T ra n s itio n a l- c e ll p a p illo m a T ra rrs itio n a l-c c ll c a rc in o m a
(tra n s itio n a l)
1. A c h o r is to m a is a s m a ll b e n ig n m a s s o f n o r m a l tis s u e m is p la c e d
w ith in a n o th e r o r g a n , s u c h a s liv e r tis s u e w it h in th e w a ll o f th e
in te s t in e .
2 . A h a m a r to m a is a b e n ig n tu m o r - lik e o v e r g r o w th o f c e ll t y p e s th a t
a r e r e g u la r ly fo u n d w it h in th e a ffe c te d o r g a n , s u c h a s a
h e m a n g io m a , a n ir r e g u la r a c c u m u la tio n o f b lo o d v e s s e ls .
n e o p la s m s 137

T h e E w in g s a r c o m a fa m ily o f tu m o r s e n c o m p a s s e s E w in g s a r c o m a
a n d p r im itiv e n e u r o e c to d e r m a l tu m o r (P N E T ), w h ic h a r e p r im a r y
m a lig n a n t s m a ll r o u n d -c e ll tu m o r s o f b o n e a n d s o ft tis s u e .
E w in g s a r c o m a a n d P N E T to g e th e r a c c o u n t fo r a p p r o x im a te ly 6 % to
1 0 % o f p r im a r y m a lig n a n t b o n e tu m o r s a n d fo llo w o s te o s a r c o m a a s
th e s e c o n d m o s t c o m m o n g r o u p o f b o n e s a r c o m a s in c h ild r e n .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e fir s t s t a te m e n t is tr u e ; th e s e c o n d is fa ls e
• t h e fir s t s ta t e m e n t is fa ls e ; th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
Part I • Volum e 13 • © 2 01 7
 • both statem ents are true
E w in g s a rc o m a a n d P N E T a re tw o v a r ia n ts o f th e s a m e tu m o r th a t d iffe r o n ly in th e ir
d e g re e o f n e u ra l d iffe re n tia tio n . T u m o r s th a t d e m o n s tr a te n e u ra l d iffe r e n tia tio n are
la b e le d PNETs, a n d th o s e th a t a re undifferentiated a re d ia g n o s e d a s Ewing
sarcom a. T h is d is tin c tio n h a s no clinical s ig n ific a n c e .
Ewing sarcom a is a c a n c e r th a t o c c u r s p r im a r ily in th e b o n e o r s o ft tis s u e . E w in g
s a rc o m a c a n o c c u r in a n y b o n e , b u t is m o s t o fte n fo u n d in th e e x tr e m itie s a n d c a n
in v o lv e m u s c le a n d th e s o ft tis s u e s a r o u n d th e tu m o r s ite . E w in g s a r c o m a c e lls c a n
a ls o m e ta s ta s iz e to o th e r a re a s o f th e b o d y in c lu d in g th e b o n e m a rro w , lu n g s , k id n e y s ,
h e a rt, a d re n a l g la n d s , a n d o th e r s o ft tis s u e s .
E w in g s a r c o m a is th e second most com m on m alignant bone tum or in c h ild re n a n d
a d o le s c e n ts ( o s te o s a r c o m a s a re th e m o s t c o m m o n ). It m o s t o fte n o c c u rs in c h ild re n
b e tw e e n th e a g e s o f 10 a n d 2 0 . T h e n u m b e r o f m a le s a ffe c te d is s lig h tly h ig h e r th a n
th e n u m b e r o f fe m a le s . T h e m a jo rity o f E w in g s a r c o m a s re s u lt fro m a chrom osom e
rearrangem ent b e tw e e n c h r o m o s o m e s #11 a n d # 2 2 .
Important: P a tie n ts a lm o s t a lw a y s p re s e n t w ith severe bone pain. T h e m o s t
im p o r ta n t a s p e c t o f th e p r e s e n ta tio n is to r e m e m b e r th a t it may be insidious a n d non­
specific.
1. C h ild re n m a y a ls o b re a k a b o n e a t th e s ite o f th e tu m o r a fte r a s e e m in g ly
m in o r tra u m a (p a th o lo g ic fra c tu re ).
2. E w in g s a r c o m a fo llo w s a n extrem ely m alignant c o u r s e w ith e a rly
m e ta s ta s e s .
3. Histologically, it is o fte n d iffic u lt to d is tin g u is h th is tu m o r fro m a
n e u r o b la s to m a o r a re tic u lu m c e ll s a rc o m a .
4. M orphologically, it h a s a r e s e m b la n c e to m a lig n a n t ly m p h o m a .
5. Prim ary m alignant bone tum ors (a ls o c a lle d s a r c o m a s o f th e b o n e ) a re
ra re , c o n s titu tin g le s s th a n 1 % o f a ll m a lig n a n t tu m o rs . M o s t b o n e tu m o r s
a re s e c o n d a ry , c a u s e d b y s e e d in g fro m a p rim a ry s ite . B o n e tu m o r s m a y
o r ig in a te in o s s e o u s o r n o n o s s e o u s tis s u e . O sseous b o n e tu m o r s a ris e
fro m b o n y s tru c tu re its e lf a n d nonosseous tum ors a r is e fro m
h e m a to p o ie tic , v a s c u la r, o r n e u ra l tis s u e s .
n e o p la s m s 138

A ll o f th e fo llo w in g a r e b e n ig n n e o p la s m s E X C E P T o n e . W h ic h o n e is
th e E X C E P T IO N ?

• adenom a
• f ib r o m a

• c a r c in o m a
• h e m a n g io m a
• lip o m a

M IC R O B IO L O G Y /P A T H O L O G Y ® * d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • c a r c in o m a
* * * A c a r c in o m a is a n in v a s iv e m a lig n a n t t u m o r d e r iv e d fr o m e p ith e lia l tis s u e
t h a t t e n d s t o m e t a s t a s iz e to o t h e r a r e a s o f t h e b o d y .
A b e n ig n t u m o r is c h a r a c t e r is t ic a lly lo c a liz e d , h a s a fib r o u s c a p s u le , a lim it e d
p o te n tia l f o r g r o w th , a r e g u la r s h a p e , a n d c e lls t h a t a r e w e ll d iff e r e n tia te d . A
b e n ig n n e o p la s m d o e s n o t in v a d e s u r r o u n d in g t is s u e o r m e t a s t a s iz e to
d is t a n t s ite s . It c a u s e s h a r m o n ly b y p r e s s u r e , o v e r p r o d u c t io n o f a h o r m o n e , o r
h e m o r r h a g e fo llo w in g u lc e r a tio n s o f a n o v e r ly in g m u c o s a l s u r fa c e . T h e y
u s u a lly d o n o t r e c u r a f t e r s u r g ic a l e x c is io n .
Im p o r ta n t: B e n ig n t u m o r s g r o w b y e x p a n s io n . M a lig n a n t t u m o r s s p r e a d b y
lo c a l in v a s io n a n d m e ta s ta s is . M e ta s ta s is is t h e s p r e a d o f a t u m o r to a
s e c o n d a r y s ite d is t a n t a n d s e p a r a t e fr o m its p r im a r y s ite ; m e t a s t a s is is a n
a b s o lu te in d ic a to r o f m a lig n a n c y . M e t a s t a s is o c c u r s v ia t h e b lo o d s tr e a m , o r
ly m p h s y s t e m . W it h ly m p h a tic m e ta s ta s is , t h e t u m o r f ir s t s p r e a d s t o lo c a l
a n d r e g io n a l ly m p h n o d e s . F r o m h e r e t h e c a n c e r d is s e m in a t e s v ia t h e b lo o d .
W it h h e m a to g e n o u s ( b lo o d s tr e a m ) m e ta s ta s is , s e c o n d a r y t u m o r n o d u le s
d e v e lo p in th e liv e r , lu n g , b r a in , b o n e m a r r o w , a n d s o m e t im e s in t h e s p le e n
a n d s o ft tis s u e .
R e m e m b e r : D iffe r e n tia tio n r e fe r s to t h e e x te n t to w h ic h n e o p la s tic
p a r e n c h y m a l c e lls r e s e m b le t h e c o r r e s p o n d in g n o r m a l p a r e n c h y m a l c e lls , b o t h
m o r p h o lo g ic a lly a n d fu n c tio n a lly ; la c k o f d iff e r e n tia tio n is c a lle d a n a p la s ia . In
g e n e r a l, b e n ig n t u m o r s a r e w e ll d iffe r e n tia te d .
n e o p la s m s 139

F o r e a c h n u m b e r e d c lin ic a l fe a tu r e lis te d b e lo w , s e le c t th e m o s t
c lo s e ly lin k e d b o n e tu m o r fr o m th e lis t p r o v id e d .

C lin ic a l F e a tu re Bone Tum or

1. A r is e s fr o m o s te o c la s ts a n d A . O s te o g e n ic s a r c o m a
o s t e o b la s ts
B . M a lig n a n t g ia n t c e ll t u m o r
2 . D e v e lo p s o n th e s u r fa c e o f b o n e
C . O s te o id o s te o m a
in s te a d o f th e in te r io r
D. C h o n d ro s a rc o m a
3 . D e v e lo p s fr o m c a r tila g e ( m a lig n a n t)
E . P a r o s te a l o s te o g e n ic s a r c o m a
4 . M o s t c o m m o n ly in lo n g b o n e s ,
e s p e c ia lly th e k n e e F . O s te o c h o n d r o m a

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 1. O s te o g e n ic s a r c o m a , 2. P a r o s te a l o s te o g e n ic s a r c o m a , 3.
C h o n d ro s a rc o m a ,
4. M a lig n a n t g ia n t c e ll tu m o r

M o s t b o n e tu m o r s a r e s e c o n d a r y , c a u s e d b y s e e d in g fr o m a p r im a r y s ite .
P r im a r y tu m o r s a r e m o r e c o m m o n in m a le s , u s u a lly c h ild r e n a n d a d o le s c e n ts ,
a lth o u g h s o m e ty p e s d o o c c u r in p e r s o n s b e tw e e n a g e s 3 5 a n d 6 0 . T h e y m a y
o r ig in a te in o s s e o u s o r n o n o s s e o u s tis s u e . O s s e o u s tu m o r s a r is e fr o m th e
b o n y s tr u c tu r e its e lf; t h e y in c lu d e c h o n d r o s a r c o m a , m a lig n a n t g ia n t c e ll tu m o r ,
o s te o g e n ic s a r c o m a ( m o s t c o m m o n ) , a n d p a r o s te a l o s te o g e n ic s a r c o m a .
N o n o s s e o u s tu m o r s a r is e fr o m h e m a to p o ie tic , v a s c u la r , a n d n e u r a l tis s u e s ;
t h e y in c lu d e c h o r d o m a , E w in g s a r c o m a , a n d fib r o s a r c o m a . In c h ild r e n , th e
m o s t c o m m o n ty p e o f b o n e tu m o r s a r e O s te o g e n ic a n d E w in g s a r c o m a s .
P rim a ry M a lig n a n t B o n e T u m o rs

Type C lin ic a l f e a tu re s

O s s e o u s o rig in

O s te o g e n ic s a rc o m a A ris e s f r o m b o n e -f o rm in g o s te o b la s t a n d b o n e -d ig e s tin g o s te o c la s t
O c c u r s m o s t c o m m o n ly in f e m u r b u t a ls o in tib ia a n d h u m e r u s ; o c c a s io n a lly ,
in fib u la , v e r te b r a , o r m a n d ib le
U s u a l ly o c c u r s in m a le s 1 0 to 3 0

P a ro s te a l o s te o g e n ic s a rc o m a D e v e lo p s o n s u r fa c e o f b o n e in s te a d o f in te rio r; p r o g re s s e s slo w ly
O c c u r s m o s t c o m m o n ly in d is ta l f e m u r ; o c c u r s in tib ia , h u m e r u s , a n d u ln a
U s u a lly d e v e lo p s in f e m a le s a g e s 3 0 to 4 0

C h o n d ro sa rc o m a D e v e lo p s f ro m c a r tila g e
D o e s n 't c a u s e p a i n , g r o w s s lo w ly , a n d is l o c a ll y r e c u r r e n t a n d in v a s iv e
O c c u r s m o s t c o m m o n ly in p e lv is , p r o x im n l f e m u r , r ib s , a n d s h o u ld e r g ir d le

U s u a l ly d e v e lo p s in m a le s a g e s 3 0 to 5 0

M a lig n a n t g ia n t c e ll tu m o r A ris e s fro m b e n ig n g ia n t c e ll tu m o r

M o s t c o m m o n ly in l o n g b o n e s , e s p e c i a l l y in k n e e
U s u a l ly o c c u r s in f e m a le s a g e s IK to 5 0
n e o p la s m s 140

W h ic h b o n e tu m o r o f n o n o s s e o u s o rig in is c h a r a c te r iz e d b y
c o n s tip a tio n a n d v is u a l d is tu r b a n c e s ?

• E w in g s a r c o m a
• fib r o s a r c o m a
• c h o rd o m a
• n o n e o f th e a b o v e

m ic r o b io l o g y / p a t h o l o g y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • chordom a
N onosseous tu m o r s a r is e fro m h e m a to p o ie tic , v a s c u la r , a n d n e u ra l tis s u e s .
P r im a r y V ln liu n a n t B o n e T u m o r s

T ype C lin ic a l fe a tu re s

N o n o s s eo u s o rig in

E w in g s a rc o m a
O r ig in a te s in b o n e m a r r o w a n d in v a d e s s h a f ts o f lo n g a n d H at b o n e s
U s u a ll y a lT cc ts l e g s , m o s t c o m m o n ly f e m u r , in n o m in a te b o n e s , r ib s , ti b ia , h u m e r u s
v e rt e b r a , a n d lib u la : m a y s p r e a d t o lu n g s
C a u s e s in c r e a s in g l y s e v e r e a n d p e rs is te n t p u in
U s u a ll y d e v e lo p s i n m a le s a g e s 1 0 to 2 0

F ib ro s a rc o m a R e la tiv e ly r a r e : o r ig in a te s in fib ro u s t is s u e o f b o n e : in v a d e s lo n g o r f ia t b o n e s
(f e m u r , ti b ia , a n d m u n d ib l c ) ; a ls o in v o lv e s p e r io s t e u m a n d o v e rl y in g m u s c le
U s u a ll y d e v e lo p s in m a le s n g e s 3 0 to 4 0

C h ordo m a D e r iv e d fro m e m b r y o n ic re m n a n ts o f n o to c h o r d : p r o g r e s s e s s lo w ly
O c c u r s a l e n d o f v e r te b r a l c o lu m n a n d in s p h e n o - o c c ip ita l, s a c ro c o c c y g e a l, a n d
v e r te b r a ! a re a s : c a u s e s c o n s t ip a tio n a n d v is u a l p ro b le m s
U s u a lly d e v e lo p s in m a le s a g e s 5 0 to 6 0

1. E w in g s a r c o m a is very rad io sen sitive a n d r e s p o n d s to chem otherapy.

2. T h e most common in d ic a tio n o f p r im a r y m a lig n a n t b o n e tu m o r s is bone
pain, w h ic h is o f g r e a t in te n s ity a t n ig h t, is a s s o c ia te d w ith m o v e m e n t a n d
is d u ll a n d u s u a lly lo c a liz e d .
3. M e ta s ta tic tu m o r s a re th e most com m on form o f s k e le ta l m a lig n a n c y .
T h e y u s u a lly d e v e lo p in la te r s ta g e s o f tu m o r p r o g re s s io n . T h e p a th w a y s
o f s p re a d in c lu d e (1) d ire c t e x te n s io n , (2 ) ly m p h a tic o r h e m a to g e n o u s
d is s e m in a tio n , a n d (3) in tr a s p in a l s e e d in g (v ia th e B a ts o n p le x u s o f v e in s ).
4. A n y c a n c e r c a n s p re a d to b o n e , b u t in adults m o re th a n 7 5 % o f s k e le ta l
m e ta s ta s e s o r ig in a te fro m c a n c e r s o f th e p ro s ta te , b re a s t, k id n e y , a n d
lu n g . In children, m e ta s ta s e s to b o n e o rig in a te fro m n e u r o b la s to m a ,
W ilm s tu m o r , o s te o s a r c o m a , E w in g s a r c o m a , a n d r h a b d o m y o s a r c o m a .
n e o p la s m s 141

W h ic h o f th e fo llo w in g is a c u ta n e o u s d is o r d e r m a r k e d b y
h y p e r k e r a to s is a n d p ig m e n ta tio n o f th e a x illa , n e c k , fle x u r e s , a n d
a n o g e n ita l re g io n ?

• d e r m a to fib r o m a
• s e b o r r h e ic k e r a to s is
• a c ro c h o rd o n
• a c a n th o s is n ig r ic a n s
• a c tin ic k e r a to s is

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c lc s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a c a n th o s is n ig r ic a n s
A c a n th o s is n ig r ic a n s is a c u t a n e o u s d is o r d e r m a r k e d b y h y p e r k e r a t o s is a n d
p ig m e n t a t io n o f th e a x illa , n e c k , fle x u r e s , a n d a n o g e n it a l r e g io n . M o r e t h a n h a lf
o f th e p a t ie n t s w it h a c a n t h o s is n ig r ic a n s h a v e c a n c e r ( G l c a r c in o m a s ,
p a r t ic u la r ly o f th e s to m a c h ) .
1 . D e r m a to fib r o m a s a r e b e n ig n n e o p la s m s t h a t a p p e a r a s s m a ll,
r e d - t o - b r o w n b u m p s ( n o d u le s ) t h a t r e s u lt fr o m a n a c c u m u la t io n o f
fib r o b la s ts .
2 . A c r o c h o r d o n o r a s k in ta g is a n e x t r e m e ly c o m m o n le s io n , m o s t
o ft e n fo u n d o n t h e n e c k , in t h e a r m p it, o r in th e g r o in .
3 . A c tin ic k e r a to s is is a p r e m a lig n a n t e p id e r m a l le s io n c a u s e d b y
e x c e s s iv e c h r o n ic e x p o s u r e t o s u n lig h t. T h e s e a r e c o m m o n ,
e s p e c ia lly o n lig h t- s k in n e d e ld e r ly p e o p le .
4. S e b o r r h e ic k e r a to s is ( S e b o r r h e ic w a r ts ) is a n e x t r e m e ly c o m m o n
b e n ig n n e o p la s m o f o ld e r p e o p le . T h e w a r t s a r e f le s h - c o lo r e d ,
b r o w n , o r b la c k g r o w t h s t h a t c a n a p p e a r a n y w h e r e o n th e s k in .
5 . K e r a t o a c a n t h o m a (K A ) is a c o m m o n s k in t u m o r . In th e p a s t it
w a s r e g a r d e d a s b e n ig n , b u t s o m e o f t h e s e t u m o r s h a v e b e e n
s e e n t o t r a n s f o r m in to s q u a m o u s c e ll c a r c in o m a (S C C ).
K e r a t o a c a n t h o m a is n o w r e g a r d e d a n d t r e a t e d b y m a n y a s a
m a lig n a n t g r o w th . It o r ig in a t e s in th e p ilo s e b a c e o u s g la n d s a n d
p a t h o lo g ic a lly r e s e m b le s S C C . It is c h a r a c t e r iz e d b y v e r y r a p id
e n la r g e m e n t , fo llo w e d b y a s ta b le p e r io d , a n d t h e n a s lo w , n a tu r a l
r e g r e s s io n . B o t h s u n lig h t a n d c h e m ic a l c a r c in o g e n s h a v e b e e n
im p lic a te d a s m a jo r f a c t o r s in th e g r o w th o f t h e tu m o r . T r a u m a ,
h u m a n p a p illo m a v ir u s , g e n e t ic f a c t o r s , a n d im m u n o c o m p r o m is e d
s t a t u s a ls o h a v e b e e n im p lic a te d a s e t io lo g ic f a c to r s . K A s o c c u r
m u c h m o r e f r e q u e n t ly in m e n t h a n in w o m e n , u s u a lly in t h e ir 7 0 s .
n e o p la s m s 142

A m e la n o m a in th e v e r tic a l g r o w th p h a s e th a t h a s in v a d e d 1 .5 m m
in to th e d e r m a l la y e r h a s a h ig h e r m e ta s ta tic p o te n tia l th a n a
m e la n o m a in th e h o r iz o n ta l g r o w th p h a s e .
T h e o v e r a ll p r o g n o s is is b e s t d e te r m in e d b y m e a s u r in g th e d ia m e te r
o f th e le s io n .

• b o th s t a te m e n ts a r e tr u e
• b o t h s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e .

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • th e fir s t s ta te m e n t is tr u e , t h e s e c o n d is fa ls e
T h e p r o g n o s is o f a m e la n o m a is b e s t d e t e r m in e d b y m e a s u r in g t h e v e r tic a l
g r o w th t h a t t h e le s io n h a s u n d e r g o n e . L e s io n s in t h e h o r iz o n t a l g r o w t h p h a s e
m a y r e m a in s tr ic tly s u p e r fic ia l f o r y e a r s . T h e s e c e lls d o n o t h a v e m e ta s ta tic
p o te n tia l, a n d th e le s io n s d o n o t e x h ib it a n g io g e n e s is . N o te : T h e p r o g n o s is
o f t h e le s io n is n o t d e t e r m in e d b y th e d ia m e t e r o f th e le s io n .
M e la n o m a s t h a t d e m o n s t r a t e g r o w th in t o th e d e r m a l la y e r s o f th e s k in a r e s a id
to b e in t h e v e rtic a l g ro w th p h a s e . H is to lo g ic a lly , a le s io n m u s t d e m o n s t r a t e
a m in im u m o f 0 .7 6 m m to a c q u ir e m e t a s t a t ic p o te n tia l. A s th e le s io n
p e n e t r a t e s d e e p e r , th e m e t a s t a t ic p o te n tia l in c r e a s e s a n d th e 5 t o 1 0 y e a r
s u r v iv a l r a te d r o p s . L e s io n s th a t p e n e tr a te > 3 .6 m m h a v e a n 8 - y e a r s u r v iv a l
r a te o f 3 3 % .
C lin ic a l w a r n in g s ig n s o f m e la n o m a s in c lu d e th e fo llo w in g :

A - a s y m m e t r ic le s io n
B - b o r d e r s a r e ir r e g u la r
C - c o lo r b e c o m e s v a r ie g a t e d o r p ig m e n te d
D - d ia m e t e r is 6 m m o r g r e a t e r ( th e s iz e o f a p e n c il e r a s e r )
E - e v o lu tio n o f th e le s io n , m e a n in g c h a n g e h a s o c c u r r e d
T r e a t m e n t o f a m e la n o m a s h o u ld b e d o n e b y s u r g ic a l e x c is io n . A s h a v e
b io p s y s h o u ld n o t b e d o n e to d e t e r m in e th e id e n tity o f a s u s p e c t e d le s io n .
b lo o d d is o rd e rs 143

T h e S c h illin g te s t m a y b e u s e d to d e te c t:

• fo la te d e fic ie n c y
• a p la s tic a n e m ia
• p e r n ic io u s a n e m ia
• m y e lo p h th is ic a n e m ia

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • p ernicio u s anem ia
A n e m ia is a c o n d itio n in w h ic h the b lo o d c a n n o t a d e q u a te ly o x y g e n a te th e tis s u e s . It
s h o w s up as a d e c re a s e d R B C c o u n t, d e c re a s e d h e m a to c rit o r d e c re a s e d h e m o g lo b in
co n c e n tra tio n .
A n e m ia m ay be c a u s e d by tw o m ajor m echanism s:
1. D ecreased red cell prod u ctio n re s u ltin g from :
° H em atop o ietic cell d am ag e fro m in fe c tio n , d ru g s, ra d ia tio n , an d o th e r sim ila r
a g e n ts
° D eficiency of factors necessary fo r hem e s y n th e s is (iron) o r D N A s y n th e s is
(vitam in B12 o r folate)
2. Increased red cell loss d u e to:
° E xtern al blood loss
° Red ceil d estru ctio n (h e m o ly tic a n e m ia )
P ern icio u s anem ia is th e m o s t c o m m o n form o f v ita m in B12 d e fic ie n c y m eg alo b lastic
anem ia. It is c o n s id e re d to be an a u to im m u n e d is o rd e r. It is c a u s e d by a lack o f intrinsic
factor, a s u b s ta n c e n e e d e d to a b s o rb v ita m in B 12 fro m th e g a s tro in te s tin a l tra ct. V ita m in
B12, in tu rn , is n e c e s s a ry fo r th e fo rm a tio n o f red b lo o d cells. B e c a u s e v ita m in B 12 is
n e e d e d by n e rv e c e lls a nd b lo o d c e lls to fu n c tio n p ro p e rly , p e rn ic io u s a n e m ia c a u s e s a
w id e v a rie ty o f sym p to m s , in c lu d in g fa tig u e , s h o rtn e s s o f b re a th , p e rip h e ra l n e u ro p a th y ,
d iffic u lty w a lk in g an d ta lk in g .
1. T h e e ry th ro c y te s th a t a re p ro d u c e d a re m acrocytic an d app ear
h yp erch ro m ic.
2. S tom atitis an d a tro p h ic g lo ss itis a re c o m m o n , a lo n g w ith a tro p h y o f the
g a s tric m u c o s a .
3. A n a bn o rm al S ch illing te s t is a te s t use d to d e te rm in e w h e th e r th e bo d y
a b s o rb s v ita m in B 12 norm ally.
4. A p lastic anem ia is th e re s u lt of an in a d e q u a te p ro d u c tio n o f e ry th ro c y te s
du e to th e in h ib itio n o r d e s tru c tio n of th e red b o n e m a rro w . It c a n be c a u se d
by ra d ia tio n , v a rio u s to x in s , an d c e rta in m e d ic a tio n s . Im portant: In d ru g -
in d u c e d a p la s tic a n e m ia s , th e e ry th ro c y te s (R B C s) a p p e a r to be
n o rm o ch ro m ic (n o rm a l cone, o f H e m o g lo b in ) an d n o rm o cytic (n o rm a l in
size).
b lo o d d is o r d e r s 144

A rte r ia l o r c a r d ia c th r o m b i u s u a lly b e g in a t s ite s o f t u r b u le n c e o r

e n d o th e lia l in ju ry .
V e n o u s th r o m b i te n d to g r o w r e tr o g r a d e fr o m th e p o in t o f a tta c h m e n t.

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e fir s t s t a t e m e n t is tr u e , th e s e c o n d is f a ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • th e firs t s ta te m e n t is tru e , th e s e c o n d is fa ls e
T h r e e p r im a r y a b n o r m a litie s th a t le a d to th ro m b u s fo r m a tio n (c a lle d V irc h o w 's tria d ):
(1) e n d o th e lia l in ju ry , (2) s ta s is o r tu r b u le n t b lo o d flo w , a n d (3) h y p e r c o a g u la b ility o f
th e b lo o d .
T h ro m b i c a n d e v e lo p a n y w h e re in th e c a r d io v a s c u la r s y s te m (e .g ., in c a rd ia c
c h a m b e rs , o n v a lv e s , o r in a rte rie s , v e in s , o r c a p illa r ie s ) . A rteria l o r c a rd ia c th ro m b i
u s u a lly b e g in a t s ite s o f tu r b u le n c e o r e n d o th e lia l in ju ry ; v e n o u s th r o m b i
c h a r a c te r is tic a lly o c c u r a t s ite s o f s ta s is . T h r o m b i a re fo c a lly a tta c h e d to th e
u n d e rly in g v a s c u la r s u rfa c e ; a rte ria l th r o m b i te n d to g r o w r e tro g ra d e fro m th e p o in t of
a tta c h m e n t, w h ile v e n o u s th r o m b i e x te n d in th e d ire c tio n o f b lo o d flo w (th u s b o th
p ro p a g a te to w a rd th e h e a rt).
M o s t v e n o u s th r o m b i o c c u r in th e s u p e r fic ia l o r d e e p v e in s o f th e le g . S u p e rfic ia l
v e n o u s th r o m b i ty p ic a lly o c c u r in th e s a p h e n o u s v e in s in th e s e ttin g o f v a r ic o s itie s .
A lth o u g h s u c h th r o m b i c a n c a u s e lo c a l c o n g e s tio n , s w e llin g , p a in , a n d te n d e r n e s s ,
th e y ra rely e m b o liz e . N e v e rth e le s s , th e lo c a l e d e m a a n d im p a ire d v e n o u s d r a in a g e d o
p r e d is p o s e th e o v e rly in g s k in to in fe c tio n s fro m s lig h t tra u m a a n d to th e d e v e lo p m e n t
o f v a r ic o s e u lce rs .
D eep v e in th ro m b o s is ( a b b re v ia te d a s D V T ) c a n c a u s e lo c a l p a in a n d e d e m a . It is
p o te n tia lly a d a n g e ro u s c o n d itio n a s a p ie c e o f th e c lo t c a n "fly " th r o u g h th e v e n o u s
c irc u la tio n a n d lo d g e in th e lu n g s g iv in g ris e to p u lm o n a r y in fa rc tio n .
1. C o n g e s tio n (h y p e re m ia ) is a lo c a liz e d in c re a s e in th e v o lu m e o f b lo o d in
c a p illa r ie s a n d s m a ll v e s s e ls . T h e r e a re tw o ty p es o f c o n g e s tio n
(h y p e re m ia ):
° A c tiv e c o n g e s tio n (a c tiv e h y p e re m ia ) re s u lts fro m lo c a liz e d a r te r io la r
d ila tio n (e .g ., in fla m m a tio n , b lu s h in g ).
° P a s s iv e c o n g e s tio n ( p a s s iv e h y p e re m ia ) re s u lts fro m o b s tru c tiv e
v e n o u s re tu rn o r in c re a s e d b a c k p re s s u re fro m c o n g e s tiv e h e a rt
fa ilu re . T w o form s:
■ A cute: o c c u rs in s h o c k o r r ig h t-s id e d h e a rt fa ilu re .
■ C h ro n ic: o f th e lu n g (m o s t o fte n c a u s e d b y le ft-s id e d h e a r t fa ilu r e )
■ C h ro n ic : o f th e liv e r (m o s t o fte n c a u s e d b y r ig h t-s id e d h e a rt
fa ilu re )
b lo o d d is o r d e r s 145

T h e b o d y s tr u c tu r e s m o s t v u ln e r a b le t o h ig h b lo o d p r e s s u r e in c lu d e
a ll o f th e fo llo w in g E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• b lo o d v e s s e ls
• s m a ll in te s tin e s
• b r a in
• k id n e y s
• h e a rt

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c lc s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • s m a ll in te s tin e s
If h y p e r t e n s io n is n o t d ia g n o s e d a n d t r e a t e d w ith a n tih y p e r t e n s iv e d r u g s , th e
in d iv id u a l c a n “w e a r o u t" ( c a r d ia c fa ilu r e ) , “b lo w o u t” ( c e r e b r o v a s c u la r
a c c id e n t) , o r “ru n o u t” ( r e n a l fa ilu r e ) .

F in d in g s in H y p e r te n s io n

F in d in g s B a s is o f F in d in g s

C a rd io v a sc u la r

B lood p ressu re persisten tly o v er 140/90 A rterioles a re co nstricted, cau sing abnorm al resistance to b lo o d flow

A n gina pain Insufficient b lo o d flow to co ro n ary v asculature

D ysp n ea o n exertion I .eft-sided heart failure

E dem a o f extrem ities R ig h t-sided heart failure

Interm ittent claudication D ecrease in b lo o d su p p ly from the peripheral v essels to the legs

N e u ro lo g ic

S evere occip ital head ach es w ith nausea V essel d am ag e w ithin the brain, characteristic o f severe hyp erten sio n
and v om iting; d ro w siness; giddiness;
anxiety; m ental im pairm ent

R enal

P olyuria; nocturia; dim in ish ed ab ility to A rteriolar n ephrosclerosis (hardening o f arterioles w ithin the kidney);
concentrate urine; prote in an d red 25% die o f renal failure
blo o d cells

O p h th a lm o lo g ic

| Retinal hem orrhage an d exu d ates | D am age to arterioles that sup p ly the retina
b lo o d d is o rd e rs 146

T h e m o s t c o m m o n c a u s e o f s e c o n d a r y h y p e r te n s io n is:

• p h e o c h r o m o c y to m a
• k id n e y d is e a s e
• h y p o th y r o id is m
• h y p e r p a r a th y r o id is m

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • k id n ey d ise a s e
T h e r e a re tw o b ro a d c a te g o r ie s o f h y p e rten s io n - p r im a r y ( o r e s s e n tia l) a n d
s e c o n d a ry h y p e r te n s io n . A p p r o x im a te ly 9 0 % to 9 5 % o f p a tie n ts d ia g n o s e d w ith
h y p e r te n s io n h a v e p r im a r y h y p e r te n s io n . U n lik e s e c o n d a ry h y p e r te n s io n , th e r e is no
kn o w n c a u se of p rim a ry h y p erten sio n . T h e r e fo r e , th e d ia g n o s is o f p rim a r y
h y p e r te n s io n is m a d e a fte r e x c lu d in g k n o w n c a u s e s th a t c o m p r is e w h a t is c a lle d
s e c o n d a ry h y p e r te n s io n .
If le ft u n tr e a te d , p rim a r y h y p e r te n s io n c a n e v e n tu a lly le a d to re tin a l c h a n g e s , le ft
v e n tr ic u la r h y p e r tr o p h y , a n d c a r d ia c fa ilu r e . G e n e tic fa c to r s in c lu d e a fa m ily h is to r y o f
h y p e r te n s io n , a n d it is m o r e c o m m o n a n d u s u a lly m o re s e v e r e in A fric a n A m e r ic a n s .
E n v iro n m e n ta l fa c to r s in c lu d e s tr e s s , o b e s ity , c ig a r e tte s m o k in g , a n d p h y s ic a l
in a c tiv ity .
1. U s u a lly , h ig h b lo o d p r e s s u r e h a s no s y m p to m s a t all. T h a t is w h y it is
o fte n c a lle d th e "sile n t killer."
2. A lth o u g h HP u s u a lly h a s n o s y m p to m s , s o m e tim e s th e fo llo w in g m a y be
e v id e n t: tire d n e s s , c o n fu s io n , v is u a l c h a n g e s , n a u s e a , v o m itin g , a n x ie ty ,
p e r s p ira tio n , p a le s k in , o r a n a n g in a -lik e p a in ( c r u s h in g c h e s t p a in ).
3. T h e th r e e b r o a d c la s s e s o f d r u g s u s e d to tr e a t p r im a r y h y p e r te n s io n a re
d iu retics (to re d u c e b lo o d v o lu m e ), v a s o d ila to rs (to d e c r e a s e s y s te m ic
v a s c u la r r e s is ta n c e ) , a n d c a rd io in h ib ito ry d ru g s (to d e c r e a s e c a r d ia c
o u tp u t).
S e c o n d ary h yp erten sio n is e le v a te d b lo o d p re s s u r e th a t re s u lts fro m an
u n d e r ly in g , id e n tifia b le , o fte n c o rr e c ta b le c a u s e . O n ly a b o u t 5 % to 1 0 % of
h y p e r te n s io n c a s e s a re th o u g h t to re s u lt fr o m s e c o n d a ry c a u s e s . Th ese causes
in c lu d e:
• R e n a l a r te r y s te n o s is • S le e p a p n e a
• C h r o n ic re n a l d is e a s e • H y p e r - o r h y p o th y r o id is m
• P r im a r y h y p e r a ld o s te r o n is m • P h e o c h r o m o c y to m a
• S tr e s s • P r e e c la m p s ia
• A o r tic c o a r c ta tio n
b lo o d d is o rd e rs 147

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith th e

n o r m o c y tic c la s s if ic a tio n o f a n e m ia .

• ir o n d e f ic ie n c y
• t h a la s s e m ia s
• a p la s tic a n e m ia
• a n e m ia o f c h r o n ic d is e a s e
• liv e r d is e a s e
• v it a m in B 1 2 a n d f o la te d e fic ie n c y
• a c u te a n d c h r o n ic b lo o d lo s s

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a p la s tic a n e m ia
• a n e m ia o f c h r o n ic d is e a s e
• a c u te a n d c h r o n ic b lo o d lo s s
A n e m ia is a c o n d it io n in w h ic h th e b lo o d c a n n o t a d e q u a t e ly o x y g e n a t e th e
tis s u e s . It s h o w s u p a s a d e c r e a s e d R B C c o u n t, d e c r e a s e d h e m a t o c r it o r
d e c r e a s e d h e m o g lo b in c o n c e n t r a t io n . T h e b o d y g e ts le s s o x y g e n a n d
th e r e f o r e h a s le s s e n e r g y th a n it n e e d s t o f u n c t io n p r o p e r ly . S y m p t o m s in c lu d e
fa tig u e , w e a k n e s s , in a b ilit y t o e x e r c is e , a n d lig h th e a d e d n e s s .

M o r p h o lo g ic a l C la s s ific a tio n s o f A n e m ia s

M a c r o c y t ic :
• L iv e r d is e a s e
• V ita m in B 1 2 a n d F o la te d e f ic ie n c y

N o r m o c y tic :
• A p la s t ic a n e m ia
• A n e m ia o f c h r o n ic d is e a s e
• A c u t e a n d c h r o n ic b lo o d lo s s

M ic r o c y tic :
• Ir o n d e f ic ie n c y
• T h a la s s e m ia s
• A n e m ia o f c h r o n ic d is e a s e
 P a th o p h y s io lo g ic C la s s ific a tio n o f A n e m ia

D e c r e a s e d p r o d u c t i o n o f R B C 's

S te m C e ll D is o r d e r s

• A p la s tic a n e m ia C a u s e d b y ra d ia tio n , v a rio u s to x in s , a n d c e rta in m e d ic a tio n s

D N A s y n th e s is d is o r d e r s

• M e g a lo b la s tic a n e m ia
- V ita m in B 12 d e fic ie n c y A u to im m u n e d is o rd e r; S to m a titis a n d a tro p h ic G lo s s itis
- F o lic a c id d e fic ie n c y C a u s e d b y s e v e re d ie tin g , p re g n a n c y , D ila n tin u s a g e

H e m o g lo b in s y n th e s is d is o r d e r s

• Iro n d e fic ie n c y M ic ro c y tic a n e m ia ; n o t a s s o c ia te d w ith d ru g u s a g e

I n c r e a s e d d e s t r u c t i o n o f R B C 's

• H e m o ly tic a n e m ia
- A u to im m u n e h e m o ly tic a n e m ia
- E r y th r o b la s to s is f e ta lis
- H e re d ita iy s p h e ro c y to s is
- T h a l a s s e m i a 's ( a l p h a & b e t a )
C a u s e d b y c e rta in d ru g s (s u c h a s A ld o m e t)
M o th e r p r o d u c e s a n tib o d ie s a g a in s t in c o m p a tib le b lo o d
S p le n o m e g a ly is o f te n p r o m in e n t
D e fic ie n t p ro d u c tio n o f e ith e r a lp h a o r b e ta -g lo b in c h a in o f
h e m o g lo b in . H y p o c h ro m ic c e lls . A lp h a , c o m m o n in S o u th e a s t
A s ia ; B e ta : c o im n o n in M e d ite r r a n e a n a n d U S

• E n z y m e d e fic ie n c y
- G lu c o s e -6 -p h o s p h a te d e h y d ro g e n a s e M o s t c o m m o n fo r m o f e n z y m e d e fic ie n c y h e m o ly tic a n e m ia
- P y r u v a te k in a s e S e c o n d m o s t c o m m o n e n z y m e d e fic ie n c y h e m o ly tic a n e m ia

• G lo b in a b n o rm a lity
- S ic k le c e ll a n e m ia S p le n o m e g a ly ; a p la s tic c ris is
b lo o d d is o rd e rs 148

W a r fa r in is a n e ffe c tiv e a n tic o a g u la n t th a t fu n c tio n s b y its

a n ta g o n is tic a c tio n o n:

• v ita m in A
• v ita m in D
• v it a m in E
• v ita m in K

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r i I - V o lu m e 1 3 - © 2 0 1 7
 • v ita m in K
W a r fa r in ( C o u m a d in ) is a n a n t ic o a g u la n t t h a t in te r fe r e s w it h v it a m in K . It
in h ib its th e fo r m a t io n o f p r o t h r o m b in in th e liv e r . T h e e f f e c t o f d e la y e d b lo o d
c lo t t in g is u s e fu l t o p r e v e n t a n d t r e a t th r o m b o e m b o lic d is e a s e .
C ir c u m s t a n c e s t h a t w ill c a u s e d e la y e d b lo o d c lo tt in g :
• A p a t ie n t t a k in g h e p a r in , w h ic h is a n a n t ic o a g u la n t . It a c ts a s a n
a n t it h r o m b in a n d a n ti p r o t h r o m b in b y p r e v e n t in g p la t e le t a g g lu t in a t io n a n d
c o n s e q u e n t b lo o d c lo t fo r m a t io n
• A p a t ie n t w it h le u k e m ia o f te n h a s th r o m b o c y t o p e n ia , w h ic h is a r e d u c e d
n u m b e r o f p la t e le t s
• P a tie n ts w it h c ir r h o s is o f th e liv e r have h y p o p r o t h r o m b in e m ia
( a b n o r m a lly s m a ll a m o u n t s o f p r o t h r o m b in in th e c ir c u la t in g b lo o d ) . N o te :
P r o th r o m b in is f o r m e d a n d s t o r e d in th e p a r e n c h y m a l c e lls o f th e liv e r . In
c ir r h o s is th e r e is p r o fu s e d a m a g e to t h e s e c e lls .
• v o n W ille b r a n d 's d is e a s e : d e f ic ie n c y o f v W F ( v o n W ille b r a n d 's F a c t o r ) ;
r e s u lt s in im p a ir e d p la t e le t a d h e s io n
• L o n g - t e r m t r e a t m e n t w it h a s p ir in : it is a c y c lo o x y g e n a s e in h ib it o r ; r e s u lt s in
im p a ir e d p r o d u c t io n of th ro m b o x a n e s , w h ic h a re im p o r t a n t p la te le t
a g g re g a n ts
• B e r n a r d -S o u lie r d is e a s e : a h e r e d it a r y p la t e le t a d h e s io n d is o r d e r
R e m e m b e r : In th e p r e s e n c e o f t h r o m b o p la s t in a n d c a lc iu m io n s , p r o t h r o m b in
is c o n v e r t e d t o t h r o m b in , w h ic h in t u r n c o n v e r t s f ib r in o g e n t o fib r in . F ib r in
th r e a d s th e n e n tr a p b lo o d c e lls , p la te le ts , a n d p la s m a t o f o r m a b lo o d c lo t.
N o te : D ic u m a r o l is a n a n t ic o a g u la n t t h a t in h ib its th e f o r m a t io n o f
p r o t h r o m b in in th e liv e r . It is u s e d t o d e la y t h e c lo ttin g o f b lo o d e s p e c ia lly in
p r e v e n t in g a n d t r e a t in g t h r o m b o e m b o lic d is e a s e . N o te : D ic u m a r o l h a s la r g e ly
b e e n r e p la c e d b y w a r fa r in .
b lo o d d is o rd e rs 149

T h e m o s t c o m m o n fo rm o f e r y th r o b la s to s is fe ta lis is A B O
in c o m p a tib ilit y , w h ic h c a n v a r y in s e v e r it y .
T h e le s s c o m m o n fo r m is c a lle d Rh in c o m p a tib ility , w h ic h c a n c a u s e
v e ry s e v e r e a n e m ia in th e b a b y .

• b o t h s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• t h e fir s t s ta te m e n t is tr u e , th e s e c o n d is f a ls e
• t h e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s t a te m e n ts a r e tr u e
E r y t h r o b la s t o s is f e t a lis is a p o t e n t ia lly lif e - t h r e a t e n in g b lo o d d is o r d e r in a fe tu s
o r n e w b o r n in f a n t. It d e v e lo p s in a n u n b o r n in fa n t w h e n th e m o t h e r a n d b a b y
h a v e d if f e r e n t b lo o d ty p e s . T h e m o t h e r p r o d u c e s a n t ib o d ie s t h a t a t t a c k th e
d e v e lo p in g b a b y 's r e d b lo o d c e lls .
A B O in c o m p a tib ility is a r e a c tio n o f th e im m u n e s y s te m t h a t o c c u r s if tw o
d if f e r e n t and not c o m p a t ib le b lo o d ty p e s a re m ix e d to g e th e r. Rh
in c o m p a t ib ilit y is a c o n d it io n th a t d e v e lo p s w h e n a p r e g n a n t w o m a n h a s R h -
n e g a tiv e b lo o d a n d th e b a b y in h e r w o m b h a s R h - p o s it iv e b lo o d .
R e m e m b e r : P a tie n ts w it h h e m o ly t ic a n e m ia s ( i.e ., e r y t h r o b la s t o s is f e ta lis ,
s ic k le c e ll a n e m ia a n d th e t h a la s s e m ia s ) o f te n h a v e p r o b le m s t h a t r e s u lt fr o m
a n in c r e a s e in b ilir u b in le v e ls . T h is b ilir u b in is th e b r e a k d o w n p r o d u c t o f
h e m o g lo b in w h ic h is r e le a s e d fr o m d y in g e r y th r o c y te s .
E x a m p le s in c lu d e :
• E le v a te d le v e ls o f u r o b ilin o g e n , w h ic h is a com pound fo rm e d in th e
in t e s t in e b y th e r e d u c t io n o f b ilir u b in .
• E le v a te d le v e ls o f u n c o n ju g a te d b ilir u b in , w h ic h is w a t e r - in s o lu b le
b ilir u b in . N o r m a lly , t h is u n c o n ju g a t e d b ilir u b in w o u ld c o m b in e w it h s e r u m
a lb u m in t o b e c o m e w a t e r - s o lu b le ( c o n ju g a te d b ilir u b in ) in t h e liv e r . T h is
w o u ld t h e n b e s e c r e t e d w it h o t h e r c o m p o n e n t s o f b ile in to th e s m a ll
in te s tin e . T o x ic a c c u m u la t io n o f u n c o n ju g a t e d b ilir u b in in t h e b r a in a n d
s p in a l c o r d is c a lle d k e r n ic te r u s .
„ 1. B e t a th a la s s e m ia m a jo r is a ls o k n o w n a s M e d it e r r a n e a n a n e m ia
o r C o o le y a n e m ia . It is c h a r a c t e r iz e d b y m a r k e d a n e m ia a n d
s p le n o m e g a ly , a s w e ll a s g e n e r a liz e d h e m o s id e r o s is .
2 . B e ta t h a la s s e m ia m in o r - c lin ic a l m a n if e s t a t io n s in c lu d e :
in c r e a s e in h e m o g lo b in A 2 .
3 . A lp h a t h a la s s e m ia s a r e th e m o s t c o m m o n f o r m s o f t h a la s s e m ia
in S o u t h e a s t A s ia .
b lo o d d is o r d e r s 150

T h e c la s s ic p e n ta d o f th r o m b o tic t h r o m b o c y to p e n ic p u r p u r a in c lu d e s
a ll o f th e fo llo w in g E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• m ic r o a n g io p a th ic h e m o ly tic a n e m ia
• t h r o m b o c y t o p e n ia
• liv e r d y s fu n c tio n
• tr a n s ie n t n e u r o lo g ic d e fic its
• fe v e r
• r e n a l fa ilu r e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • liv e r d y s fu n c tio n
T h ro m b o tic th ro m b o c y to p e n ic p u rp u ra (T T P ) is a life - th r e a te n in g m u ltis y s te m
d is o r d e r th a t is c o n s id e r e d a tru e m e d ic a l e m e r g e n c y . T T P is u s u a lly a s s o c ia te d w ith
a d e fic ie n c y in a p la s m a e n z y m e c a lle d A D A M T S 1 3 , a ls o d e s ig n a te d v o n W ille b r a n d
fa c to r ( v W F ) m e ta llo p r o te a s e . T h e e n z y m e p r o m o te s d e g r a d a tio n o f v e r y - h ig h -
m o le c u la r - w e ig h t m u ltim e r s o f v W F , a n d th e e n z y m e d e fic ie n c y r e s u lts in m u ltim e r
a c c u m u la tio n in th e p la s m a a n d c o n s e q u e n t p la te le t m ic r o a g g r e g a te fo r m a tio n . T h e
tr e a tm e n t is p la s m a e x c h a n g e . T h e d is o r d e r c a n b e fa ta l if d ia g n o s is a n d th e ra p y a re
d e la y e d .
Id io p a th ic th ro m b o c y to p e n ic p u rp u ra (IT P ) is a b le e d in g c o n d itio n in w h ic h th e
b lo o d d o e s n o t c lo t a s it s h o u ld . T h is is d u e to a lo w n u m b e r o f p la te le ts . T h e r e a re 2
ty p e s o f IT P . O n e ty p e a ffe c ts c h ild r e n , a n d th e o th e r ty p e a ffe c ts a d u lts . In c h ild re n ,
th e u s u a l a g e fo r g e ttin g IT P is b e tw e e n 2 a n d 4 y e a r s . M o s t a d u lts w ith IT P a re y o u n g
w o m e n , b u t it c a n o c c u r in a n y o n e . IT P d o e s n o t ru n in fa m ilie s .
IT P is d iffe r e n t in c h ild re n th a n in a d u lts . M o s t c h ild r e n w ith IT P h a v e a v e ry lo w
p la te le t c o u n t th a t c a u s e s s u d d e n b le e d in g . T h e u s u a l s y m p to m s a re b r u is e s a n d th e
tin y p u rp u ra s p o ts ( p e te c h ia e ) o n th e s k in . N o s e b le e d s a n d b le e d in g g u m s a re a ls o
com m on.
In m o st a d u lts, IT P la s ts m u c h lo n g e r th a n it d o e s in c h ild r e n . A t th e tim e of
d ia g n o s is , m o s t a d u lts h a v e n o tic e d in c r e a s e d b le e d in g a n d e a s y b r u is in g f o r s e v e r a l
w e e k s , o r e v e n m o n th s . In w o m e n , in c r e a s e d m e n s tru a l b lo o d f lo w is a m a jo r s ig n .
1. P u rp u ra s p o ts a r e p u rp lis h d is c o lo r a tio n s in th e s k in p r o d u c e d b y s m a ll
b le e d in g v e s s e ls n e a r th e s u r fa c e o f th e s k in . P u r p u r a m a y a ls o o c c u r in
th e m u c o u s m e m b r a n e s (s u c h a s th e lin in g o f th e m o u th ) a n d in th e
in te r n a l o rg a n s . P u r p u r a b y its e lf is o n ly a s ig n o f o th e r u n d e r ly in g c a u s e s
o f b le e d in g .
2. T h ro m b o c y to p e n ia is a c o n d itio n in w h ic h th e r e is a r e d u c e d n u m b e r o f
p la te le ts . T h is c a u s e s b le e d in g s ta te s in w h ic h b lo o d lo s s o c c u r s th r o u g h
c a p illa r ie s a n d o th e r s m a ll v e s s e ls . It is th e m o s t c o m m o n c a u s e o f
b le e d in g d is o r d e r s .
b lo o d d is o rd e rs 151

W h ic h o f th e fo llo w in g ty p e s o f a r te r io s c le r o s is is c h a r a c te r iz e d b y
c a lc ific d e p o s it s in m u s c u la r a r te r ie s in p e r s o n s ty p ic a lly o ld e r th a n
ag e 50?

• M o n c k e b e r g m e d ia l s c le r o s is
• a th e r o s c le r o s is
• a r t e r io lo s c le r o s is ( h y p e r p la s tic )
• a r te r io lo s c le r o s is ( h y a lin e )

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • M o n ckeb erg m edial sclero sis
A rterio sclero sis lite ra lly m e a n s “ h a rd e n in g o f th e a rte rie s ” ; it is a g e n e ric term re fle ctin g
a rte ria l w a ll th ic k e n in g a nd lo ss of e la s tic ity . T h e re a re th re e g e n e ra l p a tte rn s, w ith
d iffe rin g c lin ic a l a nd p a th o lo g ic co n s e q u e n c e s .
• A rterio losclero sis a ffe c ts sm a ll a rte rie s a nd a rte rio le s , a nd m a y ca u s e d o w n s tre a m
is c h e m ic injury. T h e re a re tw o a n a to m ic v a ria n ts , h y a lin e a nd h yp e rp la stic.
• M on ckeb erg m edial sclero sis is c h a ra c te riz e d by c a lc ific d e p o s its in m u s c u la r
a rte rie s in p e rs o n s ty p ic a lly o ld e r th a n a ge 50 ye a rs. T h e d e p o s its m a y un d e rg o
m e ta p la s tic c h a n g e s into bone. N e v e rth e le s s , th e le sio n s do n o t e n c ro a c h on the
v e s s e l lu m e n a nd are u s u a lly n o t c lin ic a lly s ig n ific a n t.
• A th ero sclero sis is th e m ost freq u en t a n d clin ic ally im p o rtan t p a tte rn . It is
c h a ra c te riz e d by in tim a l le s io n s c a lle d atherom as (a lso c a lle d a th e ro m a to u s or
a th e ro s c le ro tic p la q u e s ) th a t p ro tru d e into v e s s e l lum e n s. B e s id e s m e c h a n ic a lly
o b s tru c tin g b lo o d flo w , a th e ro s c le ro tic p la q u e s c a n ru p tu re , le a d in g to c a ta s tro p h ic
v e s s e l th ro m b o s is ; p la q u e s a lso w e a k e n th e u n d e rly in g m e d ia and th e re b y lead to
a n e u ry s m fo rm a tio n .
Im portant: A th e ro s c le ro s is c a u s e s fa r m o re m o rb id ity a nd m o rta lity (ro u g h ly h a lf of all
d e a th s ) in th e W e s te rn w o rld th a n a n y o th e r d iso rd e r.
C o nsequ en ces of a th e ro scle ro sis:
• Ischem ic heart d isease (IH D ) a lso c a lle d coron ary artery d isease (CAD) or coron ary
heart disease (CHD)
• Stroke
• A ortic a n d caro tid a th e ro s c le ro tic d ise a se
T h e p re v a le n c e and s e v e rity of a th e ro s c le ro s is and IH D a m o n g in d iv id u a ls a nd g ro u p s are
related to se v e ra l risk fa cto rs. R isk fa cto rs have a m u ltip licative effect; tw o ris k facto rs
in c re a s e th e ris k a p p ro x im a te ly fo u rfo ld . W h e n th re e ris k fa c to rs a re p re s e n t (e.g.,
h y p e rlip id e m ia , h y p e rte n s io n , a nd s m o k in g ), th e ris k o f m y o c a rd ia l in fa rc tio n is in cre a se d
se ve n tim es.
C o nstitu tio n al risk facto rs (less c o n tro lla b le ) in IHD in c lu d e age, g e n d e r, a nd g e n e tics.
M od ifiab le risk facto rs in IH D in clu d e h y p e rlip id e m ia , h y p e rte n s io n , c ig a re tte s m o kin g ,
a nd d ia b e te s.
b lo o d d is o rd e rs 152

In s ic k le c e ll a n e m ia , th e g lo b in p o rtio n o f th e m o le c u le is a b n o r m a l
d u e to th e a m in o a c id v a lin e b e in g s u b s tit u te d fo r w h ic h o f th e
fo llo w in g a m in o a c id s ?

• g lu ta m in e
• g lu ta m ic a c id
• a s p a r tic a c id
• g ly c in e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 * g lu ta m ic acid
S ic k le c e ll a n e m ia is th e m o st c o m m o n h e re d ita ry a n e m ia o f p e r s o n s o f A fr ic a n
lin e a g e . It is c a u s e d b y a n a b n o r m a l ty p e o f h e m o g lo b in ( o x y g e n c a r r y in g m o le c u le )
c a lle d h e m o g lo b in S. It is in h e r ite d a s a n a u to s o m a l re c e s s iv e tr a it; th a t is, it o c c u r s
in s o m e o n e w h o h a s in h e r ite d h e m o g lo b in S fr o m b o th p a r e n ts . T h e g lo b in p o r tio n o f
th e m o le c u le is a b n o r m a l d u e to th e a m in o a c id v a lin e b e in g s u b s titu te d fo r
g lu ta m ic a c id in th e s ix th p o s itio n o f th e h e m o g lo b in m o le c u le . W h e n th e a b n o r m a l
h e m o g lo b in m o le c u le s a re e x p o s e d to lo w c o n c e n tr a tio n s o f o x y g e n (h y p o x ic
c o n d itio n s ), th e y fo r m fib r o u s p re c ip ita te s w ith th e e r y th r o c y te s , d is to r tin g th e m in to
th e s ic k le s h a p e ( c r e s c e n t s h a p e ) c h a r a c te r is tic o f th e d is e a s e . A s a r e s u lt, th e y
fu n c tio n a b n o r m a lly a n d c a u s e s m a ll b lo o d c lo ts . T h e s e c lo ts g iv e ris e to r e c u r re n t
p a in fu l e p is o d e s c a lle d "sickle cell pain crises."
_ 1. N o n -h e alin g leg u lce rs a n d r e c u r re n t b o u ts o f a b d o m in a l c h e s t pain
a re c h a ra c te r is tic o f s ic k le c e ll a n e m ia .
2 . P a tie n ts w ith s ic k le c e ll a n e m ia c a n b e c o m e fu n c tio n a lly a s p le n ic . A s a
re s u lt, th e y a re p ro n e to in fe c tio n s c a u s e d b y e n c a p s u la te d o r g a n is m s
( in c lu d in g Streptococcus pneumonia a n d Hemophilus influenza).
S a lm o n e lla b o n e in fe c tio n s /o s te o m y e litis c a n o c c u r.
3. R e p e a te d e p is o d e s o f s p le n ic in fa r c tio n fo llo w e d b y fib r o tic h e a lin g le a d
to a fib r o tic , s h r u n k e n s p le e n (a u to s p le n e c to m y ) in a d u lt p a tie n ts w ith
s ic k le c e ll a n e m ia
4. S ic k le c e ll a n e m ia m a y b e c o m e life - th r e a te n in g w h e n d a m a g e d re d
b lo o d c e lls b r e a k d o w n (h e m o ly tic c ris is ), w h e n th e s p le e n e n la r g e s
a n d tr a p s th e b lo o d c e lls (s p le n ic s e q u e s tra tio n crisis), o r w h e n a
c e r ta in ty p e o f in fe c tio n c a u s e s th e b o n e m a r r o w to s to p p r o d u c in g re d
b lo o d c e lls (a p la s tic crisis). R e p e a te d c r is e s c a n c a u s e d a m a g e to th e
k id n e y s , lu n g s , b o n e s , e y e s , a n d c e n tra l n e r v o u s s y s te m .
5. B lo c k e d b lo o d v e s s e ls a n d d a m a g e d o r g a n s c a n c a u s e a c u te p a in fu l
e p iso d e s . T h e s e p a in fu l c r is e s , w h ic h o c c u r in a lm o s t a ll p a tie n ts at
s o m e p o in t in th e ir liv e s , c a n la s t h o u r s to d a y s , a ffe c tin g th e b o n e s o f th e
b a c k , th e lo n g b o n e s , a n d th e c h e s t.
b lo o d d is o rd e rs 153

A m a n w h o h a s h a d flu -lik e s y m p to m s , b u t w it h o u t a fe v e r , n o w
s h o w s a c h e r r y -r e d d is c o lo r a tio n o f th e s k in , m u c o s a a n d tis s u e s . H e
is m o s t lik e ly s u ffe r in g fr o m a n a c u te :

• c a r b o n m o n o x id e p o is o n in g
• m e r c u r y p o is o n in g
• f lu o r id e p o is o n in g
• s a r c o id o s is
• m ilia r y tu b e r c u lo s is

M IC R O B IO L O G Y /P A T H O L O G Y ® * d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • c a r b o n m o n o x id e p o is o n in g
T h e a f f in it y b e tw e e n C O a n d h e m o g lo b in is 2 0 0 t im e s s tr o n g e r t h a n th e
a ff in ity b e tw e e n h e m o g lo b in a n d o x y g e n .
O n e o f t h e im p e r f e c t io n s o f th e h u m a n b o d y is th a t, g iv e n a c h o ic e b e tw e e n
c a r b o n m o n o x id e a n d o x y g e n , t h e p r o te in h e m o g lo b in in o u r b lo o d w ill a lw a y s
la tc h o n t o c a r b o n m o n o x id e a n d ig n o r e t h e life - g iv in g o x y g e n . B e c a u s e o f th is
n a tu r a l c h e m ic a l a ffin ity , o u r b o d ie s , in e ff e c t, r e p la c e o x y g e n w ith c a r b o n
m o n o x id e in o u r b lo o d s tr e a m , c a u s in g g r e a t e r o r le s s e r le v e ls o f c e ll
s u ff o c a tio n d e p e n d in g o n t h e in te n s ity a n d d u r a t io n o f e x p o s u r e .
W h e n t h e r e a r e e v e n m in u te a m o u n ts o f c a r b o n m o n o x id e in t h e a ir t h a t is
b r e a th e d , th e y p r e fe r e n tia lly occupy th e o x y g e n - b in d in g s ite s o f th e
h e m o g lo b in m o le c u le s . T h is h e m o g lo b in - c a r b o n m o n o x id e b o n d is s o s tr o n g
t h a t v e r y little c a r b o n m o n o x id e is r e m o v e d fr o m t h e b lo o d . P a tie n ts w ith
a c u te c a r b o n m o n o x id e p o is o n in g e x h ib it c h e r r y -r e d d is c o lo r a tio n o f th e
s k in , m ucosa, and tis s u e s . U lt im a te ly , d e a th w ill occur due to
h y p o x ia . Im p o r ta n t: T h e s y m p t o m s o f lo w - le v e l c a r b o n m o n o x id e p o is o n in g
a r e s o e a s ily m is ta k e n f o r th o s e o f th e c o m m o n c o ld , flu o r e x h a u s tio n t h a t
p r o p e r d ia g n o s is c a n b e d e la y e d .
O t h e r e n v ir o n m e n t a l c h e m ic a l a g e n t s a n d t h e ir m a n ife s ta tio n if in g e s te d :
• C a r b o n t e tr a c h lo r id e : h e p a t o c e llu la r d a m a g e
• M e r c u r ic c h lo r id e : s e v e r e r e n a l t u b u la r n e c r o s is a n d G l u lc e r a tio n
• C y a n id e p o is o n in g : p r e v e n ts c e llu la r o x id a tio n , r e s u lts in o d o r o f b itt e r
a lm o n d s
• M e th y l a lc o h o l: b lin d n e s s
• B is m u th : n a u s e a , v o m itin g a n d a b d o m in a l p a in u s u a lly o c c u r w it h in h o u r s
a n d p r e c e d e f e a t u r e s o f n e p h r o t o x ic it y a n d n e u r o to x ic ity
• L e a d : b a s o p h ilic s ti p p lin g o f R B C s , a n e m ia , a b d o m in a l p a in , a n d w r is t a n d
fo o t d r o p
b lo o d d is o rd e rs 154

H e m o p h ilia A a n d v o n W ille b r a n d D is e a s e b o th d ir e c tly in v o lv e

c lo ttin g fa c to r V III.
H e m o p h ilia B a ls o d ir e c tly a ffe c ts c lo ttin g fa c to r V III.

• b o th s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r i I ‘ V o lu m e 1 3 ‘ © 2 0 1 7
 • th e firs t s ta te m e n t is tru e , th e s ec o n d is fals e
H e m o p h ilia A a n d B a r e in h e r ite d a s a s e x -lin k e d re c e s s iv e tra it b y w h ic h m a le s
a r e a ffe c te d a n d fe m a le s a r e c a r rie r s . T h e m a jo r ity o f p e o p le a fflic te d w ith h e m o p h ilia
h a v e ty p e A a n d it p re s e n ts u n d e r th e a g e o f 2 5 y e a r s . T h e s ig n s , s y m p to m s , a n d
c lin ic a l m a n ife s ta tio n s in c lu d e e x c e s s iv e b le e d in g fr o m m in o r c u ts , e p is ta x is ,
h e m a to m a s , a n d h e m a r th r o s e s .
C la s s ific a tio n s o f H em o p h ilia :
• H e m o p h ilia A: c o n s id e r e d th e c la s s ic a l ty p e , c a u s e d b y a d e fic ie n c y o f
c o a g u la tio n fa c to r V III ( a n ti- h e m o p h ilic fa c to r ).
• H e m o p h ilia B ( a ls o c a lle d C h r is tm a s d is e a s e ) : d u e to a d e fic ie n c y in fa c to r IX
( p la s m a - th r o m b o p la s tin c o m p o n e n t) .
• H e m o p h ilia C ( a ls o c a lle d R o s e n th a l's s y n d ro m e ): not s e x -lin k e d , le s s s e v e r e
b le e d in g . D u e to a d e fic ie n c y o f fa c to r XI ( p la s m a th ro m b o p la s tin a n te c e d e n t) .
Im p o rta n t: A tr u e h e m o p h ilia c is c h a r a c te riz e d b y h a v in g th e fo llo w in g :
• P ro lo n g e d p a r tia l th r o m b o p la s tin tim e (P T T )
• N o rm a l p r o th r o m b in tim e (P T )
• N o rm a l th r o m b in tim e
• N o rm a l b le e d in g tim e
• N o rm a l p la te le t c o u n t
1. In c la s s ic h e m o p h ilia , th e o th e r la b te s ts re m a in n o rm a l, b e c a u s e th e
b le e d in g tim e is a m e a s u r e o f p la te le t p lu g fo rm a tio n , th e p r o th r o m b in
tim e a m e a s u r e o f th e e x trin s ic p a th w a y o f c o a g u la tio n , a n d th e th r o m b in
tim e a n a s s a y o f th e c o n v e r s io n o f fib r in o g e n to fib r in .
2. vo n W ille b ra n d 's d is e a s e is in h e r ite d a s a n a u to s o m a l d o m in a n t
b le e d in g d is o r d e r , it o c c u r s w ith e q u a l fr e q u e n c y in b o th s e x e s . It r e s u lts
fr o m a d e fic ie n c y in th e v o n W ille b r a n d fa c to r , w h ic h is a la rg e
g ly c o p r o te in th a t h a s b in d in g s ite s fo r fa c to r V III a n d a ls o fa c ilita te s th e
a d h e s io n o f p la te le ts to c o lla g e n ( im p o r ta n t in th e fo rm a tio n o f a p la te le t
p lu g ) .
b o n e d is o rd e rs 155

W h ic h o f th e fo llo w in g o c c u r s m o s t c o m m o n ly in e ld e r ly w o m e n a n d
is a s s o c ia te d w ith th e p o s tm e n o p a u s a l s ta te a n d e s tr o g e n
d e fic ie n c y ?

• o s te o g e n e s is im p e r fe c ta
• o s te o p o r o s is
• m y a s th e n ia g r a v is
• o s te o a r th r itis

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • osteoporosis
Osteoporosis is a d is e a s e c h a ra c te riz e d by p o ro u s bo n e s and a re d u ce d bon e m ass. T he
a s s o c ia te d stru c tu ra l c h a n g e s p re d is p o s e th e bo n e to fra c tu re . T h e m o s t c o m m o n fo rm s
are s e n ile a nd p o stm e n o p a u s a l o s te o p o ro s is , in w h ich th e loss of bo n e m a ss m a ke s th e
ske le to n v u ln e ra b le to fra ctu re s. F a cto rs in v o lv e d in th e p a th o g e n e s is of o s te o p o ro s is
in c lu d e (1) age-related changes in b o n e c e lls a nd m a trix ha ve a s tro n g im p a c t on bone
m e ta b o lism , (2) reduced physical activity in c re a s e s th e rate of b o n e loss b e ca u se
m e c h a n ic a l fo rc e s s tim u la te no rm a l bo n e re m o d e lin g , (3) genetic factors are also
im p o rta n t, (4) th e b o d y's calcium nutritional state is im p o rta n t, (5) hormonal influences
- p o stm e n o p a u s a l o s te o p o ro s is is c h a ra c te riz e d by a h o rm o n e -d e p e n d e n t a c c e le ra tio n of
bo n e loss th a t o c c u rs d u rin g th e d e c a d e a fte r m e n o p a u s e . Estrogen deficiency p la ys a
m a jo r ro le in th is p h e n o m e n o n . Note: H y p e rp a ra th y ro id is m , le u k e m ia , ly m p h o m a , and
m ultip le m y e lo m a can a lso c a u s e o ste o p o ro s is .
Osteoarthritis (aka d e g e n e ra tiv e jo in t d is e a s e ) is th e m o st co m m o n ty p e of jo in t disease.
It is c h a ra c te riz e d by th e progressive erosion of articular cartilage. T h e term
o ste o a rth ritis im p lie s an infla m m a to ry d is e a s e ; how e ve r, e ven th o u g h in fla m m a to ry cells
m a y be p re s e n t (u s u a lly in s m a ll n u m b e rs), o s te o a rth ritis is c o n s id e re d to be an in trin sic
d is e a s e of c a rtila g e in w h ich b io c h e m ic a l a nd m e ta b o lic a lte ra tio n s in in d iv id u a ls w ith
g e n e tic s u s c e p tib ility re s u lt in its b re a k d o w n . D uring th e s ta g e s of o s te o a rth ritis d is lo d g e d
p ie c e s of c a rtila g e and s u b c h o n d ra l b o n e tu m b le into th e jo in t, fo rm in g lo o se b o d ie s (joint
mice). T h e e x p o s e d su b c h o n d ra l b o n e p la te b e c o m e s th e n e w a rtic u la r s u rfa c e , and
fric tio n w ith th e o p p o s in g d e g e n e ra te d a rtic u la r s u rfa c e s m o o th s a nd b u rn is h e s the
e xp o s e d bone, givin g it th e a p p e a ra n c e o f p o lis h e d ivo ry (bone eburnation).
Note: Osteophytes (b o n y s p u rs ) can fo rm a t th e d is ta l in te rp h a la n g e a l jo in ts (Heberden
nodes) o r a t th e p ro x im a l in te rp h a la n g e a l jo in ts (Bouchard nodes).
1. Osteogenesis imperfecta (or b rittle b o n e d is e a s e ) is an a u to s o m a l d o m in a n t
d is o rd e r c h a ra c te riz e d by m u ltip le fra c tu re s w ith m in im a l tra u m a . It is ca u s e d
by m u ta tio n s in e ith e r o f th e g e n e s th a t c o d e fo r typ e I c o lla g e n . T h e blue
sclerae, h e a rin g loss, and d e n ta l a b n o rm a litie s a re c h a ra c te ris tic . T h e te e th
a re p o o r b e c a u s e of m a lfo rm a tio n of d e n tin (d e n tin o g e n e s is im p e rfe cta ).
2. Myasthenia gravis is an a u to im m u n e d is o rd e r ca u s e d by a u to a n tib o d ie s to
p o s ts y n a p tic a c e ty lc h o lin e re c e p to rs o f th e n e u ro m u s c u la r ju n c tio n . T he
d is e a s e c o m m o n ly p re s e n ts as ptosis, d ip lo p ia , a nd d iffic u lty c h e w in g ,
s p e a k in g , o r s w a llo w in g .
b o n e d is o rd e rs 156

A ll o f t h e fo llo w in g a r e fe a tu r e s o f A lb e r s -S c h o n b e r g d is e a s e E X C E P T
o n e . W h ic h o n e is th e E X C E P T IO N ?

• a n e m ia
• m u lt ip le b o n e f r a c tu r e s
• d e c r e a s e d b o n e d e n s it y
• b lin d n e s s
• d e a fn e s s

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • decreased bone density
O steopetrosis, a ls o k n o w n a s m a rb le b o n e d is e a s e a n d A lb e r s - S c h o n b e r g d is e a s e ,
re fe rs to a g ro u p of ra re g e n e tic d is e a s e s th a t a re c h a r a c te r iz e d b y reduced bone
resorption a n d diffuse sym m etric skeletal sclerosis d u e to im p a ire d fo r m a tio n or
fu n c tio n o f o s te o c la s ts . T h e te rm o s te o p e tro s is re fle c ts th e s to n e lik e q u a lity o f th e
b o n e s ; h o w e v e r, th e b o n e s a re a b n o r m a lly b rittle a n d fr a c tu r e e a s ily , lik e a p ie c e of
c h a lk . It o c c u r s in tw o m a jo r c lin ic a l fo r m s : (1) a n a u to s o m a l re c e s s iv e m a lig n a n t
in fa n tile fo rm , w h ic h is th e m o s t s e v e re fo rm of th is d is o r d e r a n d d e a th , u s u a lly o c c u rs
in th e fir s t d e c a d e of life , a n d (2) a le s s s e v e re a u to s o m a l d o m in a n t v a ria n t.
T h e main features o f th is d is e a s e are:
• M u ltip le fra c tu r e s in s p ite o f in c re a s e d b o n e d e n s ity
• A n e m ia a s a re s u lt o f d e c r e a s e d m a rro w s p a c e
• B lin d n e s s , d e a fn e s s , a n d c ra n ia l n e rv e in v o lv e m e n t due to n a rro w in g and
im p in g e m e n t o f n e u ra l fo r a m in a
O th e r non-neoplastic d is e a s e s o f b o n e :
•A ch o n d ro p la s ia is o n e o f th e m o s t c o m m o n c a u s e s o f d w a r fis m . It is an
a u to s o m a l d o m in a n t d is o r d e r c h a r a c te r iz e d b y s h o r t lim b s w ith n o r m a l-s iz e d h e a d
a n d tru n k .
• Scurvy is c a u s e d b y a v ita m in C d e fic ie n c y . It is c h a r a c te r iz e d b y b o n e le s io n s
le a d in g to im p a ire d o s te o id m a trix fo r m a tio n w h ic h is c a u s e d b y th e fa ilu r e o f th e
p ro lin e a n d ly s in e h y d ro x y la tio n re q u ire d fo r c o lla g e n s y n th e s is .
• von Recklinghausen disease of bone (o s te itis fib r o s a c y s tic a ) is c a u s e d by
p rim a ry o r s e c o n d a ry h y p e r p a r a th y r o id is m . W id e s p r e a d o s te o ly tic le s io n s a re
c h a r a c te r is tic
• O steom alacia is c a u s e d b y a v ita m in D d e fic ie n c y in a d u lts . D e fe c tiv e c a lc ific a tio n
o f o s te o id m a trix is c h a ra c te ris tic .
• Rickets is c a u s e d b y a v ita m in D d e fic ie n c y in c h ild re n .
• Fibrous dysplasia is c h a ra c te riz e d b y n o rm a l b o n e b e in g re p la c e d b y fib ro u s
tis s u e . T h e re a re th r e e c la s s ific a tio n s d e p e n d in g o n e x te n s iv e n e s s o f s k e le ta l
in v o lv e m e n t: (1 ) M onostotic: o n e b o n e , (2 ) Polyostotic: m o re th a n o n e b o n e , a n d
(3 ) P o ly o s to tic w ith a s s o c ia te d e n d o c r in e d is tu r b a n c e s (A lb rig h t s y n d ro m e ).
Pathologic fractures a re o fte n th e p re s e n tin g c o m p la in t.
b o n e d is o rd e rs 157

F o r e a c h n u m b e re d s ite o f o s te o c h o n d r o s is lis te d b e lo w , s e le c t th e
m o s t c lo s e ly lin k e d d is o r d e r fr o m th e lis t p ro v id e d .

S ite
1. H e a d o f f e m u r
2. T ib ia l tu b e r o s ity
3. T a r s a l n a v ic u la r b o n e
4. In te r v e r t e b r a l jo in ts
5. M e t a t a r s a l h e a d
D is o r d e r
A . K o h le r d is e a s e
B . F r e ib e r g in fr a c tio n
C . S c h e u e r m a n n d is e a s e
D . P e r th e s ’ d is e a s e
E . O s g o o d - S c h la tt e r d is e a s e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I - V o lu m e 1 3 * © 2 0 1 7
 • 1. P e r th e s ' d is e a s e , 2. O s g o o d -S c h la tte r d is e a s e , 3 . K o h le r d is e a s e ,
4. S c h e u e r m a n n d is e a s e , 5 . F re ib e r g in fr a c tio n
O s te o c h o n d r o s is ( o s te o c h o n d r it is ) is a te r m u s e d to d e s c r ib e a g r o u p o f
d is o r d e r s th a t a ffe c t th e g r o w in g s k e le t o n . T h e s e d is o r d e r s r e s u lt fr o m a b n o r m a l
g r o w th , in ju r y , o r o v e r u s e o f th e d e v e lo p in g g r o w th p la te a n d s u r r o u n d in g
o s s if ic a tio n c e n te r s . T h e e x a c t e tio lo g y o f t h e s e d is o r d e r s is u n k n o w n , b u t
g e n e t ic c a u s e s , r e p e titiv e tr a u m a , v a s c u la r a b n o r m a lit ie s , m e c h a n ic a l fa c to r s ,
a n d h o r m o n a l im b a la n c e s m a y a ll p la y a ro le .
In g r o w in g c h ild r e n , o s te o c h o n d r o s is m a y in v o lv e a v a r ie ty o f c h a r a c te r is tic s ite s
in c lu d in g :
• H e a d o f th e fe m u r - P e r th e s 1 d is e a s e
• T ib ia l t u b e r o s ity - O s g o o d -S c h la tte r d is e a s e
• T a r s a l n a v ic u la r b o n e - K o h le r d is e a s e
• In te r v e r te b r a l jo in ts - S c h e u e r m a n n d is e a s e
• M e ta ta r s a l h e a d ( u s u a lly 2 n d , le s s c o m m o n ly in th e 1 s t a n d 3 rd ) - F re ib e rg
in fra c tio n
D u r in g th e y e a r s o f r a p id b o n e g r o w th , b lo o d s u p p ly to th e g r o w in g e n d s o f
b o n e s ( e p ip h y s e s ) m a y b e c o m e in s u ff ic ie n t r e s u ltin g in n e c r o tic b o n e , u s u a lly
n e a r jo in ts . T h e te r m a v a s c u la r n e c ro s is is u s e d to d e s c r ib e o s te o c h o n d r o s is .
T h is in v o lv e s th e d e g e n e r a t io n fo llo w e d b y r e o s s ific a t io n o f o n e o r m o r e
o s s if ic a tio n c e n te r s in c h ild r e n . S in c e b o n e is n o r m a lly u n d e r g o in g a c o n tin u o u s
r e b u ild in g p r o c e s s , th e n e c r o tic a r e a s a r e m o s t o fte n s e lf - r e p a ir e d o v e r a p e r io d
o f w e e k s o r m o n th s . T h e y a r e c h a r a c t e r iz e d b y d e g e n e r a tio n a n d a s e p tic
n e c ro s is fo llo w e d b y r e g e n e r a tio n a n d re o s s ific a tio n .
O s te o c h o n d r o s is c a n a ff e c t th e o s s ific a tio n c e n t e r o f th e e n d s o f b o n e s . A
ty p ic a lc o n d it io n is O s g o o d -S c h la tte r d is e a s e , w h ic h is c h a r a c te r iz e d b y
lo c a liz e d p a in a n d s w e llin g o v e r th e tib ia l tu b e r c le o r a t th e p a te lla r te n d o n
in s e r t io n . It is u s u a lly s e e n in a th le tic te e n a g e r s a n d r e s p o n d s to lo c a l t r e a tm e n t
a n d c h a n g e s in s p o r tin g a c tiv itie s . S e v e r 's d is e a s e is a n o s te o c h o n d r itis o f th e
in s e r tio n o f th e a c h ille s te n d o n in to th e c a lc a n e u m .
b o n e d is o rd e rs 158

O s te it is d e fo r m a n s p re s e n ts a s a m ix e d r a d io p a q u e a n d ra d io iu c e n t
le s io n B E C A U S E th e m ix e d s ta g e o f th e d is e a s e fe a tu r e s p r o m in e n t
o s te o ly s is a n d o s te o g e n e s is .

• b o t h th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t a n d r e la t e d
• b o th th e s ta te m e n t a n d th e r e a s o n a r e c o r r e c t b u t N O T r e la te d
• th e s ta te m e n t is c o r r e c t , b u t th e r e a s o n is N O T
• th e s ta te m e n t is N O T c o r r e c t , b u t th e r e a s o n is c o r r e c t
• n e it h e r th e s ta te m e n t N O R th e r e a s o n is c o r r e c t

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • both the statem ent and the reason are correct and related
O s t e it is d e fo r m a n s ( P a g e t's d is e a s e o f th e b o n e ) is a m e t a b o lic b o n e d is e a s e th a t
in v o lv e s b o n e d e s t r u c tio n a n d r e g ro w th th a t r e s u lts in d e fo r m ity . T h e c a u s e o f P a g e t's
d is e a s e is not entirely known, b u t it is th o u g h t to b e c a u s e d in p a r t fr o m a c h ild h o o d
v ir u s . A v ir u s p a r tic le , k n o w n a s a param yxovirus n u c le o c a p s id , h a s b e e n id e n tifie d
w ith in th e b o n e c e lls o f in d iv id u a ls w ith P a g e t's d is e a s e . T h is v ir u s p a r t ic le is n o t fo u n d
in n o r m a l b o n e . W h ile th is r e la t io n s h ip h a s b e e n id e n t if ie d , a c le a r c o n n e c tio n
b e tw e e n th e v ir u s a n d th e c a u s e o f P a g e t's d is e a s e is n o t k n o w n .
P a g e t's d is e a s e m o s t c o m m o n ly in v o lv e s th e s p in e , p e lv is , c a lv a r iu m o f th e s k u ll,
fe m u r , a n d tib ia . T h e d is e a s e m a y lo c a liz e to o n e ( m o n o s to tic ) o r tw o ( p o ly o s to tic )
a r e a s w it h in th e s k e le to n , o r b e c o m e w id e s p r e a d . T h e s k u ll m a y e n la r g e h e a d s iz e
a n d c a u s e h e a r in g lo s s , if th e c r a n ia l n e r v e s a r e d a m a g e d b y th e b o n e g ro w th .
Abnorm al bone architecture c a u s e d b y in c r e a s e s in b o th o s te o b la s tic a n d
o s te o c la s tic a c t iv ity is c h a r a c te r is tic .
1 . Intraorally th e te e t h s p r e a d .
2 . T h e s e p a tie n ts a r e predisposed to d e v e lo p in g osteosarcom as.
3 . L a b o r a t o r y fin d in g s in c lu d e : a n e m ia , m arkedly increased serum alkaline
phosphatase le v e ls ( a n in d e x o f o s te o b la s tic a c tiv it y a n d b o n e fo r m a t io n ) ,
a s w e ll a s a n e le v a te d 2 4 - h o u r u rin e le v e l fo r h y d r o x y p ro lin e ( a n a m in o
a c id e x c r e te d b y th e k id n e y s a n d a n in d e x o f o s te o c la s tic h y p e r a c tiv ity ) .
4 . M ix e d o s te o b la s t ic a n d o s te o ly tic p h a s e o f b o n e fo r m a tio n le a d s to a
c h a r a c te r is t ic h is to lo g ic m osaic pattern, a n d a c la s s ic cotton-wool
a p p e a ra n c e .
5 . S e r u m a lk a lin e p h o s p h a t a s e le v e ls a r e s o m e tim e s e le v a t e d in p a tie n t s
w ith prostate cancer.
6. Von R ecklinghausen's d is e a s e o f b o n e ( o s te it is fib r o s a c y s tic a ) is
c h a r a c te r iz e d b y d e c r e a s e d s e r u m p h o s p h o r u s a n d a n in c r e a s e in s e ru m
c a lc iu m a n d a lk a lin e p h o s p h a ta s e .
7 . C ondensing osteitis ( s c le r o s in g o s te itis ) is a d if fu s e r a d io p a q u e le s io n
r e p r e s e n t in g a lo c a liz e d b o n y r e a c tio n to a lo w - g r a d e in f la m m a to r y
s tim u lu s , u s u a lly s e e n a t t h e a p e x o f a to o th . It h a s a s p e c ia l p r e d ile c t io n
f o r m a n d ib u la r m o la r s .
b o n e d is o r d e r s 159

R ic k e ts o c c u r s o n ly in c h ild r e n ; its ty p ic a l a d u lt c o u n te r p a r t is c a lle d :

• o s te itis fib r o s a c y s tic a

• o s te itis d e fo r m a n s
• o s te o p e tr o s is
• o s te o m a la c ia
• o s te o m y e litis

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • o s te o m a la c ia
O s te o m a la c ia m e a n s " s o ft b o n e s .” O s te o id is th e b o n e p r o te in m a tr ix ,
c o m p o s e d p r im a r ily o f ty p e 1 c o lla g e n . W h e n t h e r e is in s u f f ic ie n t v ita m in D o r
o s te o b la s t d y s fu n c tio n , th e o s te o id d o e s n o t m in e r a liz e p r o p e r ly , a n d it
a c c u m u la te s . W h e n th e n e w ly fo r m e d b o n e o f th e g r o w th p la te d o e s n o t
m in e r a liz e , th e g r o w th p la te b e c o m e s th ic k , w id e a n d ir r e g u la r . T h is r e s u lts in
th e c lin ic a l d ia g n o s is o f ric k e ts , a n d is s e e n o n ly in c h ild r e n b e c a u s e a d u lts n o
lo n g e r h a v e g r o w th p la te s . W h e n th e r e m o d e le d b o n e d o e s n o t m in e r a liz e ,
o s te o m a la c ia o c c u r s , a n d th is h a p p e n s in a ll a g e s . M o s t o f th e h e r e d it a r y
c a u s e s o f o s te o m a la c ia a p p e a r d u r in g c h ild h o o d a n d c a u s e r ic k e ts .
O s te o m a la c ia :
• V ita m in D d e fic ie n c y in a d u lts
• A p p e a r s to b e m o r e c o m m o n in w o m e n
• It is c h a r a c te r iz e d b y d iffu s e r a d io lu c e n c ie s , w h ic h c a n m im ic o s t e o p o r o s is
* * * B o n e b io p s y is o f te n th e o n ly w a y to d iff e r e n tia te b e tw e e n o s t e o p o r o s is
a n d o s te o m a la c ia .
• S y m p to m s m a y in c lu d e d if fu s e b o n e p a in ( e s p e c ia lly in th e h ip s ) , m u s c le
w e a k n e s s , a n d b o n e f r a c tu r e s w ith m in im a l tr a u m a
R ic k e ts :
• V ita m in D d e fic ie n c y in c h ild r e n
• C lin ic a l m a n ife s ta tio n s in c lu d e :
o S k u ll: c r a n io ta b e s m a y o c c u r , in w h ic h th e b o n e s o f th e s k u ll s o f te n , a n d
fla tt e n in g o f th e p o s te r io r s k u ll c a n b e s e e n ,
o T e e th : te e th m a y e ru p t la te r th a n n o rm a l because of under
m in e r a liz a tio n . E n a m e l c a n b e o f p o o r q u a lity , r e s u ltin g in c a r ie s .
° T h o ra x :
■ r a c h it ic ro s a r y - th ic k e n in g o f th e c o s to c h o n d r a l ju n c tio n s
■ h a rr is o n g r o o v e — th e g r o o v e is a s e m ic o r o n a l im p r e s s io n o v e r th e
a b d o m e n a t th e le v e l o f th e in s e r t io n o f th e d ia p h r a g m
b o n e d is o rd e rs 160

O r d e r th e h is to lo g ic s ta g e s o f fr a c tu r e h e a lin g . M a tc h e a c h le tte r w ith

its p r o p e r s e q u e n c e n u m b e r .

• 1 . _ _ A . R e p la c e m e n t o f c a llu s b y la m e lla r b o n e
• 2 . _ _ B . R e m o d e lin g o f b o n e t o n o r m a l c o n to u r
• 3 . _ _ C . F r a c tu r e
• 5 . _ _ E. F o r m a t io n o f g r a n u la tio n tis s u e a r o u n d f r a c tu r e d b o n e c e lls
• 4 . _ _ D . R e p la c e m e n t o f g r a n u la tio n t is s u e b y c a llu s

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 1 . C , 2. E , 3 . D, 4 . A , 5. B
5 h is to lo g ic s ta g e s o f f r a c t u r e h e a lin g :
1. F r a c tu r e
2. F o r m a tio n o f g r a n u la t io n t is s u e a r o u n d f r a c t u r e d b o n e e n d s
3. R e p la c e m e n t o f g r a n u la t io n t is s u e b y c a llu s
4. R e p la c e m e n t o f c a llu s b y la m e lla r b o n e
5. R e m o d e lin g o f b o n e t o n o r m a l c o n t o u r
3 p h a s e s o f t h e h e a lin g o f fra c tu r e s :

t . F rac tu re
| R e a c tiv e p h a s e
2 . F o r m a t i o n o f g r a n u l a t i o n t is s u e a r o u n d f r a c t u r e d b o n e

ends
3 . R e p la c e m e n t o f g r a n u l a t i o n ti s s u e b y c a llu s
| R e p a r a tiv e p h a s e
4 . R e p la c e m e n t o f c a l lu s b y la m e l l a r b o n e
5 . R e m o d e li n g o f b o n e t o n o r m a l c o n t o u r } R e m o d e lin g p h a s e

F r a c tu r e s fa il to h e a l ( n o n - u n io n ) f o r th e fo llo w in g r e a s o n s :
• Is c h e m ia : th e n a v ic u la r b o n e o f th e w r is t, th e fe m o r a l n e c k , a n d th e lo w e r
th ir d o f th e t ib ia a r e a ll p o o r ly v a s c u la r iz e d a n d a r e th e r e f o r e s u b je c t to
c o a g u la tio n n e c r o s is a f t e r a fr a c t u r e
• E x c e s s iv e m o b ility : p s e u d o a r t h r o s is o r a p s e u d o jo in t m a y o c c u r
• In te r p o s itio n o f s o ft tis s u e b e tw e e n th e f r a c t u r e d e n d s
• In fe c tio n : m o s t lik e ly w it h c o m p o u n d f r a c t u r e s
Im p o r ta n t: A f a t e m b o lis m is m o s t o ft e n a s e q u e la o f f r a c t u r e d b o n e s d u e to
th e m e c h a n ic a l d is r u p t io n o f b o n e m a r r o w f a t a n d b y a lt e r a t io n s in p la s m a
lip id s .
h e a rt d is o r d e r s 161

W h ic h o f th e fo llo w in g is th e m o s t c o m m o n v ira l c a u s e o f
p e r ic a r d itis ?

• m um ps
• in f lu e n z a e
• h e rp e s
• H IV
• c o x s a c k ie B v ir u s a n d e c h o v ir u s

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • coxsackie B viru s and echovirus
T h e pericardial sac c o n ta in s u p to 5 0 m L o f p e r ic a r d ia l flu id in th e n o rm a l h e a rt. T h e
p e ric a rd iu m s e r v e s to lu b ric a te th e s u rfa c e o f th e h e a rt, p r e v e n ts d e fo r m a tio n a n d
d is lo c a tio n o f th e h e a rt a n d a c ts a s a b a r rie r to th e s p re a d o f in fe c tio n . P e ric a rd ia l
in fla m m a tio n (pericarditis) m a y o c c u r s e c o n d a ry to a v a r ie ty o f c a r d ia c d is e a s e s ,
th o r a c ic o r s y s te m ic d is o r d e r s , m e ta s ta s e s fro m n e o p la s m s a r is in g in r e m o te s ite s , o r
a s u rg ic a l p r o c e d u r e o n th e h e a rt. Prim ary p e r ic a r d itis is u n u s u a l a n d a lm o s t a lw a y s
o f viral o rig in . M o s t c a u s e s e v o k e a n a c u te p e ric a r d itis , b u t a fe w , s u c h as
tu b e r c u lo s is a n d fu n g i, p r o d u c e c h r o n ic re a c tio n s .
C iiu se s o f P e ric a rd itis

I n fe c tio u s A g e n ts P r e s u m a b ly I m m u n o lo g lc a lly M e d ia te d M is c e lla n e o u s

V ir u s e s ( C o x s a c k ie v iru s , e c h o v iru s , R h e u m a tic fe v e r M y o c a r d ia l in f a r c tio n

m u m p s , h e rp e s . H IV ) S y s te m ic lu p u s e ry th e m a to s u s U re m ia

P y o g e n ic b a c te ria ( S ta p h y lo c o c c u s . S tre p to c o c c u s . S c le ro d e rm a F o llo w in g c a rd ia c s u rg e ry

P n e u m o c o c c u s . M e n in g o c o c c u s . H a e m o p h ilu s P o s tc a rd io to m y N e o p la s ia

in flu e n z a e . M y c o p la s m o s is . B o r r c lio s is . C h la m y d ia ) D ru g h y p e rs e n s itiv ity r e a c tio n T rau m a

T u b e rc u lo s is R a d ia tio n

F u n g i ( H is to p la s m o s is , C o c c id io id o m y c o s is )

Important: C a r d ia c ta m p o n a d e (ty p e o f p e ric a r d ia l e ffu s io n in w h ic h flu id a c c u m u la te s

in th e p e r ic a r d iu m ) is th e most serious com plication o f p e r ic a r d itis . S ig n s a n d
s y m p to m s in c lu d e Beck's triad ( d e c re a s e d b lo o d p re s s u re , m u ffle d h e a rt s o u n d s , a n d
a b u lg in g o r d is te n s io n o f th e v e in s in th e n e c k ), d ia p h o r e s is a n d c o o l, c la m m y s k in ,
a n x ie ty , re s tle s s n e s s , s y n c o p e a s w e ll a s a w e a k , ra p id p u ls e , ta c h y p n e a a n d
o rth o p n e a .
C onstrictive pericarditis is a s e r io u s fo rm o f p e r ic a r d itis in w h ic h th e p e r ic a r d iu m
b e c o m e s s o th ic k e n e d a n d s c a r re d th a t it lo s e s s o m e o f its e la s tic ity . It c o m p re sse s
th e h e a rt, in te r fe r e s w ith th e a b ility o f th e h e a rt to fill u p w ith b lo o d , a n d r e d u c e s th e
a m o u n t o f b lo o d p u m p e d o u t to th e b o d y . C o n s tr ic tiv e p e ric a r d itis m a y c a u s e h e a rt
fa ilu r e a n d le a d to k id n e y d is e a s e . Sym ptom s include: c h e s t p a in , d iffic u lty in
b r e a th in g , s w e llin g o f th e fe e t a n d a n k le s , fa tig u e , a n d w e a k n e s s .
Important: A o r tic d is s e c tio n , a ls o c a lle d dissecting aneurysm c h a r a c te r is tic a lly
re s u lts in a o r tic ru p tu re , m o s t o fte n in to th e p e ric a r d ia l s a c , c a u s in g fa ta l c a r d ia c
ta m p o n a d e .
h e a rt d is o r d e r s 162

T h e m o s t c o m m o n c a u s e o f rig h t-s id e d h e a r t f a ilu r e is:

• le f t- s id e d h e a r t fa ilu r e
• h y p e r te n s io n
• is c h e m ic h e a r t d is e a s e
• a o r tic a n d m itra l v a lv u la r d is e a s e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • left-sided h eart failure
H eart failu re is a lm o s t a lw a y s a c h ro n ic , lo n g - te rm c o n d itio n , a lth o u g h it c a n s o m e tim e s
d e v e lo p s u d d e n ly . T h is c o n d itio n m a y a ffe c t th e r ig h t s id e , th e le ft s id e , o r b o th s id e s of
th e h e a rt. U s u a lly th e le ft v e n tr ic le fails first, s o o n fo llo w e d b y th e r ig h t- s id e d fa ilu re .
T h e com m o n sig ns o f C H F include:
• E x e r tio n a l d y s p n e a
• P a r o x y s m a l n o c tu rn a l d y s p n e a ( p a tie n t w a k e s u p g a s p in g fo r a ir)
*** T h e a b o v e tw o s ig n s are th e earliest and m ost com m o n s ig n s
• P e r ip h e r a l e d e m a ( s w o lle n a n k le s )
• C y a n o s is
• O r th o p n e a ( s ittin g o r s ta n d in g in o r d e r to b re a th e c o m fo r ta b ly )
• H ig h v e n o u s p re s s u re
L eft-sided heart failure:
• C auses
• C lin ical m a nifestation s
• Ischem ic heart disease, e s p e c ia lly Ml
• D y s p n e a a n d o r th o p n e a
• H ypertension • P le u ra l e ffu s io n w ith h y d r o th o ra x
• A o rtican d m itral v alvu lar d isease • R e d u c tio n in re n a l p e r fu s io n
• M yocardial d isease, s u c h as • C e re b ra l a n o x ia
c a rd io m y o p a th ie s and m y o c a rd itis
R ig h t-sided h eart failure:
• Causes
• C lin ical m an ifestation s
• Left-sid ed heart failure, m o st c o m m o n
ca u se • R e n a l h y p o x ia , le a d in g to flu id
• P u lm o n ary h yp erten sion re te n tio n a n d p e r ip h e r a l e d e m a
• T ricu sp id o r p ulm o n ary v alvu lar • E n la r g e d a n d c o n g e s te d liv e r a n d
disease s p le e n
• C ard iom yo p athies a n d d iffu se • D is te n tio n o f th e n e c k v e in s
m yo card itis
Im portant: P a tie n ts w ith C H F s h o u ld b e in u prigh t p o s itio n d u r in g d e n ta l tr e a tm e n t
to d e c r e a s e c o lle c tio n o f flu id in lu n g s . W h e n fu lly re c lin e d in th e d e n ta l c h a ir, th e s e
p a tie n ts m a y e x p e rie n c e d iffic u lty in b re a th in g .
h e a rt d is o rd e rs 163

W h ic h o f th e fo llo w in g ty p e s o f a n g in a is c h a r a c te r iz e d b y p ro lo n g e d
o r re c u r r e n t c h e s t p a in a t re s t?

• s t a b le a n g in a
• u n s ta b le a n g in a
• P r in z m e ta l's a n g in a
• v a r ia n t a n g in a

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • u n s ta b le an g in a
A n g in a P e c to r is is r e c u r rin g a c u te c h e s t p a in o r d is c o m fo r t r e s u ltin g fr o m d e c r e a s e d
b lo o d s u p p ly to th e h e a r t m u s c le ( m y o c a r d ia l is c h e m ia ) . A n g in a o c c u r s w h e n th e
h e a r t's n e e d fo r o x y g e n in c r e a s e s b e y o n d th e le v e l o f o x y g e n a v a ila b le fr o m th e
b lo o d flo w in g in to th e h e a r t. A n g in a is th e c la s s ic s y m p to m fo r c o r o n a r y a r te r y
d is e a s e (C A D ) . T h e s y m p to m s o f a n g in a in c lu d e m ild o r s e v e r e p a in , p r e s s u r e , o r
d is c o m fo r t in th e c h e s t. T h e p a in is g e n e ra lly d e s c rib e d a s a fe e lin g o f a s q u e e z in g ,
s tra n g lin g , h e a v in e s s , o r s u ffo c a tio n s e n s a tio n in th e c h e s t.
T yp e s o f a n g in a:
• S ta b le a n g in a is a re p e a tin g p a tte r n o f c h e s t p a in w h ic h h a s n o t c h a n g e d in
c h a r a c te r , fr e q u e n c y , in te n s ity o r d u r a tio n fo r s e v e r a l w e e k s . T h e le v e l o f a c tiv ity
o r s tr e s s th a t p r o v o k e s a n g in a is p r e d ic ta b le a n d th e p a tte r n c h a n g e s s lo w ly .
S ta b le a n g in a is th e m o s t c o m m o n fo r m a n d it a p p e a rs g r a d u a lly . Im p o r ta n t: It is
p re c ip ita te d b y e x e r tio n b u t re lie v e d b y re s t o r v a s o d ila to rs , s u c h a s n itro g ly c e r in .
• U n sta b le a n g in a is c h e s t p a in th a t is v a r ia b le , e ith e r in c r e a s in g in fr e q u e n c y o r
in te n s ity a n d w ith ir r e g u la r tim in g o r d u r a tio n . Im p o rta n t: It is p r o lo n g e d o r
r e c u r re n t p a in a t re s t. It is o fte n in d ic a tiv e o f im m in e n t m y o c a r d ia l in fa r c tio n .
• P rin zm e ta l's o r v a ria n t a n g in a is c a u s e d b y a v a s o s p a s m , w h ic h is a s p a s m
th a t n a r ro w s th e c o r o n a r y a r te r y a n d le s s e n s th e b lo o d flo w to th e h e a rt.
Im p o rta n t: It is in te r m itte n t c h e s t p a in a t re s t.
C A D a ls o k n o w n a s is c h e m ic h e a r t d is e a s e (IH D ) is a c o n d itio n in w h ic h a th e r o m a s
( a th e r o s c le r o tic p la q u e s ) a c c u m u la te in th e c e lls lin in g th e w a ll o f a c o r o n a r y a r te r y
a n d o b s tr u c t th e b lo o d flo w . A s a n o b s tr u c tio n o f a c o ro n a ry a r te r y w o r s e n s , is c h e m ia
( in a d e q u a te o x y g e n s u p p ly d u e to d e c re a s e d b lo o d flo w ) to th e h e a r t m u s c le c a n
d e v e lo p , c a u s in g h e a r t d a m a g e . T h e m a jo r c o m p lic a tio n s o f c o r o n a r y d is e a s e a re
a n g in a a n d h e a r t a tta c k .
In m o r e th a n 9 0 % o f c a s e s , th e c a u s e o f m y o c a r d ia l is c h e m ia is re d u c e d b lo o d flo w
d u e to o b s tr u c tiv e a th e r o s c le r o tic le s io n s in th e c o ro n a ry a r te r ie s . T h u s , IH D is o fte n
te rm e d c o r o n a r y a r te r y d is e a s e (C A D ) o r C H D .
T h e p rim a ry e ffe c t o f C A D is th e lo s s o f o x y g e n a n d n u trie n ts to m y o c a r d ia l tis s u e s
b e c a u s e o f d im in is h e d c o r o n a r y b lo o d flo w .
h e a r t d is o r d e r s 164

W h ic h o f t h e fo llo w in g is th e f ir s t c a r d ia c m a r k e r to in c r e a s e a fte r a
m y o c a r d ia l in fa r c tio n ?

• c r e a tin e k in a s e
• tr o p o n in

• m y o g lo b in
• la c ta te d e h y d r o g e n a s e

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • m y o g lo b in
M y o g lo b in is o n e o f s e v e r a l c a rd ia c m a r k e r s u s e d to m a k e th e d ia g n o s is . C a r d ia c
m a r k e r s a re s u b s ta n c e s in b lo o d w h o s e le v e ls ris e in th e h o u r s fo llo w in g a h e a rt
a tta c k . In c r e a s e d le v e ls h e lp d ia g n o s e a h e a r t a tta c k ; p e r s is te n t n o r m a l le v e ls r u le it
o u t.
C a rd ia c m a rk e rs e le v a te d a fte r a m y o c a rd ia l in farc tion :
T ro p o n in
• R is e s : 3 -6 h o u r s • P eaks: 20 h o u rs • D u r a tio n : 14 d a y s
S u b u n its : (1 ) T ro p o n in T (2 ) T ro p o n in I ( > 1 .0 s u g g e s ts A c u te M l)
C re a tin e P h o s p h o k in a s e (C P K )
• R is e s : 4 - 6 h o u r s • P e a k s : 1 2 -2 4 h o u rs • D u r a tio n : 4 - 5 d a y s
S u b u n its ( F r a c tio n a te to C K - M B o n ly if C P K in c r e a s e d )
• C K - M B F r a c tio n ( d u r a tio n fo r 2 - 3 d a y s )
• C K - M B ( > 5 % o f to ta l C P K s u g g e s ts M y o c a r d ia l In ju ry )
M y o g lo b in
A d v : F irs t c a r d ia c m a rk e r to in c r e a s e D isa d : P o o r S p e c ific ity ( o n ly h e lp s if
n e g a tiv e )
• R is e s : 1 -2 h o u r s • P eaks: 4 -6 h o u rs • D u r a tio n : 1 -2 d a y s
G lu ta m ic o x a lo a c e tic tra n s a m in a s e ( A S T , S G O T )
• P e a k s : 2 4 - 3 6 h o u rs • D u ra tio n : 5 d a y s
L actic D e h y d ro g e n a s e (L D H )
• P eaks: 2 4 -4 8 h o u rs • D u ra tio n : 14 d a y s
M y o c a r d ia l in fa r c tio n s ( M is ) a re m o st c o m m o n ly c a u s e d by co ro n a ry
a th e ro s c le r o s is w h ic h c a u s e s a n in te r ru p tio n in th e s u p p ly o f b lo o d to th e h e a rt. T h e
s ig n s a n d s y m p to m s in c lu d e a c ru s h in g p a in in th e a r e a o f th e c h e s t o v e r th e h e a rt,
s w e a tin g , a n d G l u p s e t. T h e p r o g n o s is o f p a tie n ts is fa ir ly g o o d if th e y re a c h th e
h o s p ita l. M o s t d e a th s o c c u r o u ts id e th e h o s p ita l d u e to a rrh y th m ia s c a u s in g
v e n tr ic u la r fib r illa tio n . A n g in a p e c to r is p a in is s im ila r to M l p a in e x c e p t it is r e lie v e d
b y re s t o r n itr a te s . M is a r e c o m m o n in m a le s a n d p o s tm e n o p a u s a l w o m e n .
h e a r t d is o r d e r s 165

A p p r o x im a te ly 5 0 % o f c a s e s o f s u b a c u te (b a c te r ia l) e n d o c a r d itis a r e
c a u s e d by:

• Serratia
• Pseudomonas
• Staphylococcus aureus
• Streptococcus viridans

M IC R O B IO L O G Y /P A T H O L O G Y ® * d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • Streptococcus viridans
In fec tio u s e n d o c a rd itis is a n in fla m m a tio n o f th e h eart v a lve s . E n d o c a r d itis is
d is tin g u is h e d fro m in fe c tio n s o f h e a r t m u s c le ( m y o c a r d itis ) o r th e lin in g o f th e h e a rt
( p e r ic a r d itis ) .
M a n y b a c te r ia c a n c a u s e e n d o c a rd itis in p a tie n ts w ith u n d e r ly in g v a lv e p r o b le m s , b u t
a s tr e p to c o c c i c o m m o n ly fo u n d in th e m o u th , Streptococcus viridans, is
r e s p o n s ib le fo r a p p ro x im a te ly h a lf o f a ll b a c te r ia l e n d o c a rd itis . O th e r c o m m o n
o r g a n is m s in c lu d e Staphylococcus aureus a n d e n te r o c o c c u s . L e s s c o m m o n
o r g a n is m s in c lu d e Pseudomonas, Serratia, a n d Candida. Staphylococcus aureus
c a n in fe c t n o rm a l h e a r t v a lv e s , a n d is th e m o s t c o m m o n c a u s e o f in fe c tio u s
e n d o c a r d itis in in tr a v e n o u s d ru g u s e rs .
C h a r a c te r is tic s in c lu d e la rg e , s o ft, fr ia b le , e a s ily d e ta c h e d v e g e ta tio n s c o n s is tin g of
fib r in a n d in te r m e s h e d in fla m m a to r y c e lls a n d b a c te r ia . C o m p lic a tio n s m a y in c lu d e
u lc e ra tio n , o fte n w ith p e r fo r a tio n , o f th e v a lv e c u s p s o r r u p tu r e o f o n e o f th e c h o r d a e
te n d in e a e .
C la s s ific a tio n o f in fe c tio u s e n d o c a rd itis :
• A c u te e n d o c a rd itis : is c a u s e d b y p a th o g e n s s u c h a s Staphylococcus aureus
( a p p r o x im a te ly 5 0 % o f c a s e s ) . T h is ty p e o f e n d o c a r d itis is o fte n s e c o n d a ry to
in fe c tio n o c c u r r in g e ls e w h e r e in th e b o d y .
• S u b a c u te (b a c te ria l) e n d o c a rd itis: is c a u s e d b y le s s v ir u le n t o r g a n is m s s u c h
a s Streptococcus viridans ( a p p r o x im a te ly 5 0 % o f c a s e s ). T h is ty p e o f e n d o c a rd itis
te n d s to o c c u r in p a tie n ts w ith c o n g e n ita l h e a r t d is e a s e o r p r e e x is tin g v a lv u la r
h e a r t d is e a s e , o fte n o f r h e u m a tic o rig in . N o te: F e v e r is a h a llm a rk o f a c u te a n d
s u b a c u te e n d o c a rd itis .
1. T h e m itra l v a lv e is m o s t fr e q u e n tly in v o lv e d .
2. T h e m itra l v a lv e a lo n g w ith th e a o rtic v a lv e is in v o lv e d in a b o u t 4 0 %
of cases.
3. T h e tric u s p id v a lv e is in v o lv e d in m o re th a n 5 0 % o f c a s e s o f
e n d o c a rd itis o f IV d ru g u s e rs .
4. M u rm u rs re s u lt fro m c h a n g e s in b lo o d flo w a c r o s s v a lv e s w h e n
v e g e ta tio n s c o lle c t o n th e v a lv e s .
in fe c tio n s 166

T h e m o s t c o m m o n ly e n c o u n te r e d n e c k s p a c e in fe c tio n is:

• a n g io e d e m a
• V in c e n t's a n g in a
• L u d w ig 's a n g in a
• h e r e d ita r y a n g io e d e m a

M IC R O B IO L O G Y /P A T H O L O G Y I* d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • L u d w ig 's a n g in a
A lth o u g h n o t s e e n o fte n , L u d w ig 's a n g in a , w h e n it d o e s o c c u r, u s u a lly is a n e x te n s io n
o f in fe c tio n fro m th e m a n d ib u la r m o la r te e th in to th e flo o r o f th e m o u th , s in c e th e ir
ro o ts lie b e lo w th e a tta c h m e n t o f th e m y lo h y o id m u s c le . T h e in fe c tio n h a s th e
fo llo w in g c h a r a c te r is tic s : F irs t, it is a b ra w n y in d u r a tio n th a t d o e s n 't p it o n p r e s s u r e .
N o flu c tu a n c e is p r e s e n t. S e c o n d ly , th r e e fa c ia l s p a c e s a re in v o lv e d b ilaterally:
s u b m a n d ib u la r , s u b m e n ta l, a n d s u b lin g u a l s p a c e s . T h ird ly , th e p a tie n t h a s a ty p ic a l
o p e n m o u th e d a p p e a ra n c e . Note: It h as a rap id o n se t. D y s p h a g ia , d y s p n e a , a n d fe v e r
a re p re s e n t.
L u d w ig 's a n g in a m a y in v o lv e s w e llin g to th e e x te n t th a t it b lo c k s th e a irw a y . T h is is an
e m e rg e n c y situ ation ! T h e g o a l o f e m e r g e n c y tre a tm e n t is to m a in ta in a n o p e n a irw a y .
T h is m a y in v o lv e in tu b a tio n (b re a th in g tu b e p la c e d th r o u g h th e m o u th o r n o s e a n d in to
th e lu n g s ) o r tr a c h e o s to m y (d ire c t o p e n in g to th e lu n g s th r o u g h s u r g ic a l p la c e m e n t of
a tu b e a t th e b a s e o f th e n e c k ). T h e g o a l o f tre a tm e n t o f th e d is o r d e r is e r a d ic a tio n of
th e in fe c tio n .
A n tib io tic s , u s u a lly p e n ic illin o r p e n ic illin - lik e d ru g s , a re g iv e n to tre a t th e in fe c tio n .
U s u a lly th e s e a re g iv e n in tr a v e n o u s ly (in a v e in ) u n til th e s y m p to m s d im in is h , th e n th e
a n tib io tic s a re c o n tin u e d a s o ra l m e d ic a tio n s u n til c u ltu r e s a re n e g a tiv e . M o s t c a s e s of
L u d w ig 's a n g in a a p p e a r to b e a m ix ed in fe c tio n . H o w e v e r, S tre p to c o c c i a re a lm o s t
a lw a y s p r e s e n t.
1. A c tin o m y c o s is (a ls o c a lle d lu m p y ja w ) is a c h r o n ic in fe c tio n w ith
A c tin o m y c e s , u s u a lly A. israelii. It is c h a r a c te r iz e d b y s lo w -g ro w in g ,
d ee p , lu m p y a b s c e s s e s th a t e x tru d e a th in , p u ru le n t e x u d a te th ro u g h
m u ltip le s in u s e s . It d e v e lo p s c h ie fly in th e ja w a n d n e c k , le s s fr e q u e n tly in
th e lu n g s a n d a lim e n ta r y tr a c t. T h e d is e a s e o c c u r s fo llo w in g tis s u e
d a m a g e th a t is c o n ta m in a te d w ith th e e n d o g e n o u s o rg a n is m . It c a n
b e tre a te d w ith lo n g -te rm P e n . th e r a p y . R em em b er: Actinomyces
naeslundii\s a g r a m - p o s itiv e , b ra n c h in g , fila m e n to u s b a c te r ia th a t is a
n o rm a l in h a b ita n t o f th e g in g iv a l c re v ic e a n d to n s illa r c ry p ts .
2. A c tin o m y c o tic le s io n s h a v e th e c h a r a c te r is tic “s u lfu r g ra n u le s ” in th e m
w h ic h a re a c tu a lly c o lo n ie s o f in fe c tin g o r g a n is m s .
in fe c tio n s 167

T e ta n o s p a s m in is a n e u r o to x in th a t in a c tiv a te s p r o te in s th a t r e g u la te
th e re le a s e o f w h ic h o f th e fo llo w in g n e u r o tr a n s m itte r s ?

• g ly c in e a n d 5 - H T
• n o r e p in e p h r in e a n d e p in e p h r in e
• G A B A a n d 5 -H T
• 5 - H T a n d e p in e p h r in e
• g ly c in e a n d G A B A

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • glycine and GABA
Tetanus, a ls o kn o w n as lo ckja w , is an a c u te e x o to x in -m e d ia te d in fe ctio n c a u se d by the
a n a e ro b ic , s p o re -fo rm in g , g ra m -p o s itiv e b a c illu s Clostridium tetani. It o c c u rs th ro u g h a pun cture
w ou n d th a t is c o n ta m in a te d by soil o r dust.
T e ta n u s to xin (sp e cifica lly, tetanospasm in) is a n e u ro to x in th a t in a c tiv a te s p ro te in s th a t
re g ula te re le a se o f th e inh ib ito ry n e u ro tra n s m itte rs glycine and GABA. T h is le a d s to
u n re g u la te d e xcita to ry s y n a p tic a ctiv ity in th e m o to r n e u ro n s, resu ltin g in spastic paralysis. T he
to xin b in d in g is irre ve rsib le , so re co very d e p e n d s on w h e th e r new a xo n a l te rm in a ls form .
G eneralized tetan u s is th e m o s t co m m o n fo rm . In vo lv e m e n t o f th e m a s s e te r m u scle s (trism u s
o r lo ckja w ) is th e p re se n tin g sign in m o s t p a tie n ts. T h e ch a ra c te ris tic s a rd o n ic s m ile th a t re su lts
fro m th e s u s ta in e d c o n tra c tio n o f th e fa cia l m u s c le s is k n o w n a s risus sardonicus. O th e r e a rly
s ig n s a re d ro o lin g , sw e a tin g , irrita bility, a nd p e rs is te n t b a ck s p a s m s (opisthotonos).
1 . D iphtheria toxin: in h ibits p ro te in s yn the sis.
2. Anthrax toxin: is m a d e u p o f th re e p ro tein s. O n e is a p rotective antigen and tw o
a re e n z y m e s th a t a re c a lle d edem a factor and lethal factor, re sp e ctive ly.
B otulinum to xin (B T X ) is p ro d u ce d by Clostridium botulinum, a g ra m -p o s itiv e a n a e ro b ic
b a cte riu m . T h e c lin ica l syn d ro m e o f b o tu lism ca n o c c u r fo llo w in g in g e stio n o f c o n ta m in a te d food,
fro m c o lo n iz a tio n o f th e in fa n t g a s tro in te s tin a l tra c t, o r fro m a w o u n d infectio n.
T h is to xin is th e m ost potent toxin know n to h u m an s. It p re ve n ts th e relea se o f the
n e u ro tra n s m itte r acetylcholine, th u s b lo ckin g n e u ro tra n s m is s io n at p e rip h e ra l ch o lin e rg ic
s yn a p se s, le a d in g to flaccid paralysis. T h e in a bility to tra n s m it im p u lse s th ro u g h m o to r n eu ro ns
ca n c a u s e respiratory failure, re su ltin g in d ea th. A s w ith te ta n u s , re c o v e ry o f fu n c tio n a fte r
b o tu lism re q u ire s re g e n e ra tio n o f th e n e rve endings.
1. C. botulinum sp o re s a re h ig h ly re s is ta n t to h eat, b u t th e to x in s a re not.
2. T h e to xin is p ro d u c e d w ith in th e ca n n e d fo o d a nd ingested preform ed.
3. P ro p e r c a n n in g a nd h ea ting o f fo o d p re ve n ts botu lism .
4. N ausea, vo m itin g , a nd a b d o m in a l c ra m p s u su a lly p re ced e th e n eu ro lo g ica l
sym p to m s: D ry m outh, d ip lo p ia , loss of p u p illa ry refle xes, fo llo w e d by d e sce n d in g
p a ra ly s is a nd re s p ira to ry fa ilu re .
in fe c tio n s 168

E o s in o p h ilia is o fte n a s s o c ia te d w ith :

• a c u te in fe c tio n s
• v ir a l in fe c t io n s
• t u b e r c u lo s is
• p a r a s itic in fe c t io n s

M IC R O B IO L O G Y /P A T H O L O G Y d M e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • p a ra s itic in fec tio n s
L e u k o c yto s is , d e fin e d a s a w h ite b lo o d c e ll c o u n t g r e a te r th a n 1 1 ,0 0 0 p e r
mm1 34(n o rm a l ra n g e is 5 ,0 0 0 to 1 0 ,0 0 0 p e r m m 3), is fr e q u e n tly fo u n d in th e c o u rs e of
2
ro u tin e la b o r a to r y te s tin g . A n e le v a te d w h ite b lo o d c e ll c o u n t ty p ic a lly r e fle c ts th e
n o rm a l re s p o n s e o f b o n e m a rro w to a n in fe c tio u s o r in fla m m a to r y p ro c e s s .
L e u k o c y to s is

N e utrop h ils • A c u te in fe c tio n s (b ac te ria l)

• S tres s

L o s in o p h ils • A lle rg y , as th m a
• P a ras itic in fec tion s

L y m p h o cy te s • T u b e rc u lo s is
• V iral infection s

M o n o c y te s • T u b ercu lo sis
• M a la ria
• R ic k e ttsia

1. N o t all b a c te r ia l in fe c tio n s s h o w th is c h a r a c te r is tic le u k o c y to s is : fo r

e x a m p le , ty p h o id fe v e r a n d b r u c e llo s is a c tu a lly re s u lt in a d e p re s s io n of
n e u tro p h ils .
2. M a n y v ira l in fe c tio n s re s u lt in a lo w e re d n u m b e r o f le u k o c y te s
(le u k o p e n ia ), p a r tic u la r ly n e u tro p h ils . A g e n e ra l in d ic a tio n o f w h e th e r a
d is e a s e is o f b a c te ria l o r v ira l o rig in c a n b e o b ta in e d b y p e rfo rm in g a
le u ko c yte c o u n t ( p a rtic u la rly n e u tro p h ils ).
3. O n o cc a s io n , th e c irc u la tin g le v e ls o f le u k o c y te s m a y re a c h v e r y h ig h
le v e ls , up to 1 0 0 ,0 0 0 p e r m m 3 of b lo o d . S u c h an e v e n t is re fe rre d to a s a
le u k e m o id re a c tio n a n d is s o m e tim e s d iffic u lt to d iffe r e n tia te fro m
le u k © m ia
4. T h e m a rg in a tio n o f le u k o c y te s re fe rs to th e lin in g u p o f th e w h ite b lo o d
c e lls a lo n g th e w a ll o f a v e s s e l.
in fe c tio n s 169

W h ile th e c a u s e a n d c u re re m a in u n k n o w n , re s e a r c h h a s e s ta b lis h e d
a lin k b e tw e e n R e y e 's s y n d r o m e a n d th e u s e o f:

• ib u p r o fe n
• a s p ir in
• a c e ta m in o p h e n
• a m o x ic illin
• d ip h e n h y d r a m in e

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • a s p ir in
R e y e 's s y n d r o m e is a r a r e a n d p o te n tia lly fa ta l s y n d r o m e o f m ito c h o n d r ia l
d y s f u n c t io n in liv e r , b r a in , a n d e ls e w h e r e . It o c c u r s p r e d o m in a n t ly in c h ild r e n
a n d is c h a r a c t e r iz e d m o r p h o lo g ic a lly b y e x te n s iv e a c c u m u la t io n o f f a t d r o p le ts
w ith in h e p a t o c y t e s ( m ic r o v e s ic u la r s te a to s is ). Its d e v e lo p m e n t h a s b e e n
a s s o c ia te d w ith th e a d m in is t r a t io n o f a s p ir in f o r th e r e lie f o f fe v e r , b u t a c a u s a l
r e la tio n s h ip b e tw e e n a s p ir in a n d R e y e 's s y n d r o m e h a s n o t b e e n e s ta b lis h e d .
N e v e r th e le s s , a s p ir in s h o u ld b e a v o id e d in c h ild r e n w it h f e b r ile illn e s s .

T h e b a s ic ru le : D o n 't g iv e a s p ir in t o a c h ild , u n le s s s p e c if ic a lly r e c o m m e n d e d

b y th e c h ild 's d o c to r . W h e n a c h ild is t a k in g a s p ir in , s t e p s m u s t b e t a k e n to
m in im iz e th e r is k o f a c q u ir in g a v ir a l illn e s s ( s u c h a s in f lu e n z a a n d v a r ic e lla
v a c c in a tio n s ) .
_ 1. In flu e n z a ( flu ) is a v ir a l in fe c tio n t h a t c a u s e s a fe v e r , r u n n y n o s e ,
c o u g h , h e a d a c h e , m a la is e , a n d m u s c le a c h e . It is th e f e v e r a n d
c o n s t it u t io n a l s y m p t o m s t h a t d is t in g u is h in f lu e n z a f r o m th e
c o m m o n c o ld . In flu e n z a v ir u s e s (A, B, a n d C ) a r e t h e o n ly
m e m b e r s o f th e o r t h o m y x o v ir u s fa m ily . In flu e n z a A is b y f a r th e
m o s t c o m m o n a n d c a u s e s th e m o s t s e v e r e d is e a s e .
2 . R e m e m b e r : T h e in flu e n z a v ir u s e s h a v e 2 e n v e lo p e g ly c o p r o te in
s p ik e s , h e m a g g lu tin in a n d n e u r a m in id a s e , w h ic h e x h ib it th e
m a jo r it y o f a n ti g e n ic c h a n g e s . T h is is im p o r t a n t in in c r e a s in g th e
a b ilit y o f t h e v ir u s to a tt a c h to h u m a n c e lls d u r in g th e e s t a b lis h m e n t
o f a n in f e c t io n .
3 . A m a n t a d in e ( S y m m e tr e l) in h ib its th e r e p lic a tio n o f t h e in f lu e n z a A
v ir u s b y in t e r f e r in g w it h v ir a l a t t a c h m e n t a n d u n c o a tin g . It is
e ff e c tiv e in th e p r o p h y la x is a n d t r e a t m e n t o f th e in f lu e n z a A v ir u s .
O t h e r a n t iv ir a l m e d ic a t io n s in c lu d e R im a n ta d in e , Z a n a m iv ir , a n d
O s e lta m iv ir . T h e m a in m o d e o f p r e v e n tio n is t h e v a c c in e , w h ic h
c o n s is t s o f k ille d in f lu e n z a A a n d B v ir u s e s .
in fe c tio n s 170

T h e s y m p to m s o f t u b e r c u lo s is in c lu d e a ll o f th e fo llo w in g E X C E P T
o n e . W h ic h o n e is th e E X C E P T IO N ?

• a b a d c o u g h th a t la s t s 3 w e e k s o r lo n g e r
• p a in in th e c h e s t

• c o u g h in g u p b lo o d o r s p u tu m
• w e a k n e s s o r f a t ig u e

• w e ig h t g a in
• n o a p p e tite
• c h ills
• fe v e r
• s w e a tin g a t n ig h t

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 •w e ig h t gain
A n a cu te o r c h ro n ic in fe ctio n c a u se d by Mycobacterium tuberculosis, tu b e rc u lo s is (TB ) is
ch a ra c te riz e d by p u lm o n a ry infiltrates, form ation of granulom as w ith ca s e a tio n , fib ro s is , and
ca vitatio n. T h e lun g s are p rim a rily in vo lved , b u t th e in fe ctio n ca n sp re a d to o th e r o rg a n s. T B is
sp re a d th ro u g h th e a ir fro m o ne p e rso n to a n o the r. S y m p to m s o f T B d is e a s e in clu de : a bad
co ugh th a t lasts 3 w e e ks o r lon ge r, pain in th e chest, c o u g h in g up b lo od o r sp utu m , w e a kn e ss or
fa tigu e, w e ig h t loss, no a ppetite, chills, fe v e r a nd sw ea ting at night. Note: F e ve r a nd n ig ht sw eats,
th e typical h a llm a rks o f T B , m ay not be p re sen t in e ld erly p atie nts, w h o instead m ay e xh ib it a
ch a n g e in a ctivity o r w eight.
Types of Tuberculosis:
1. Primary tuberculosis:
• Initial infectio n, c h a ra cte rize d by th e d e v e lo p m e n t o f th e Gohn focu s (parenchym al lung
lesio n), w hich th en b eco m e s th e Ghon com plex (pa re nch ym al lung lesion and nodal
involvem ent)
• M o st o fte n a sym p to m a tic , it u su a lly d o e s n o t p ro g re s s to clin ic a lly e v id e n t d ise a se
2. Secondary tuberculosis:
• U su a lly re su lts fro m activation of a p rio r G hon co m p le x, w hich sp re a d s to a n e w p u lm o n ary
o r e x tra p u lm o n a ry site
• L o ca lize d le s io n s fa v o r upper lobes o f the lung, in vo lve m e n t o f hilar lymph nodes is
co m m on
• Tubercle form ation: ca s e o u s g ra n u lo m a s fre q u e n tly rupture and th e c o n te n ts a re expe lle d
and re su lt in cavitary lesions. Important: C a v ita tio n is a c h a ra c te ris tic o f s e c o n d a ry , but
not p rim ary, tu b e rcu lo sis.
1. S e co n d a ry T B m ay be c o m p lica te d by lym p h a tic h e m a to g e n o u s sp re ad , re su ltin g in
m iliary TB o r dissem inated TB. T h is re su lts in th e se e d in g o f se ve ra l o rg a n s w ith
m ultiple, sm all, m illet, seed -like lesions.
2. G ranulom atous in fla m m a tio n is c h a ra c te ris tic o f b oth p rim a ry a nd s e c o n d a ry TB.
3. T h e g ra n u lo m a o f T B is re fe rre d to a s a tubercle.
4. T B is tre a te d w ith a co m b in a tion of is o n ia zid /rifa m p in /p yra zin a m id e /e th a m b u to l.
S e rio u s sid e e ffe cts inclu de o to to xicity, n e p h ro to xicity, and m u s c le w e a kn e ss.
in fe c tio n s 171

W h ic h o f th e fo llo w in g s ig n s a r e N O T a s s o c ia te d w ith a c u te
a p p e n d ic it is ?

• C u lle n ’s a n d T u r n e r ’s s ig n s
• O b t u r a t o r s ig n
• R o v s in g s ig n
• P s o a s s ig n
• D u n p h y s ig n

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • C u lle n ’s an d T u rn e r’s s ig n s
A p p e n d ic itis is in fla m m a tio n o f th e v e r m ifo r m a p p e n d ix th a t is c o n s id e r e d a
v e s tig ial o rg a n in h u m a n s . T h e p o s itio n o f th e a p p e n d ix v a r ie s ; it is lo c a te d in a
re tro ce c a l p os itio n ( p o s te r io r to th e c e c u m ) in 5 0 % o f th e p o p u la tio n w h ile in o th e rs
it c a n b e lo c a te d o v e r th e p e lv ic b rim o r d e s c e n d in g in to th e p e lv is .
A c u te a p p e n d ic itis is th e m o st c o m m o n a c u te s u rg ic a l c o n d itio n in c h ild r e n
c a u s in g m o r b id ity in c h ild r e n . H ig h e s t in c id e n c e o c c u r s in c h ild r e n b e tw e e n th e a g e s
o f 10 a n d 2 0 y e a rs . It is u n u s u a l u n d e r th e a g e o f 2 y e a rs . It r a re ly o c c u r s a fte r a g e
5 0 . M a le s a re m o re c o m m o n ly a ffe c te d th a n fe m a le s .
It is c a u s e d b y b lo c k a g e o f th e a p p e n d ice a l lum en , c a u s in g in fe c tio n d u e to
b a c te r ia l o v e r g r o w th r e s u ltin g in in fla m m a tio n .
C la s s ic s ig n s a n d s y m p to m s a re a b d o m in a l p ain c o m m o n ly in th e rig h t lo w e r
q u ad ran t, a n o r e x ia , n a u s e a , fe v e r, a n d a m o d e r a te ly e le v a te d w h ite b lo o d c e ll c o u n t
(1 2 ,0 0 0 to 1 5 ,0 0 0 /p L ). O n p h y s ic a l e x a m in a tio n th e r e is lo c a liz e d a b d o m in a l
te n d e r n e s s a t M c B u rn e y ’s p oin t* o r o v e r th e rig h t r e c tu s m u s c le , a lo n g w ith
g u a r d in g , r ig id ity , a n d re b o u n d te n d ern e s s ( p r e s s in g th e a b d o m e n s o a s to d e e p ly
p a lp a te it a n d s u d d e n ly r e le a s in g th e e x a m in in g h a n d c a u s e s p a in ).
S ig n s th a t m a y b e a s s o c ia te d w ith a c u te a p p e n d ic itis a re :
• R o vs in g s ig n is p o s itiv e o n p a lp a tio n o f th e le ft lo w e r q u a d r a n t, w h ic h c a u s e s
p a in to b e r e fe r re d to th e rig h t lo w e r q u a d r a n t.
• P so as sig n is s u g g e s tiv e o f r e tro c e c a l a p p e n d ic itis . T h e re is in c r e a s e in p a in on
e x te n s io n o f th e rig h t th ig h w ith th e p a tie n t ly in g o n th e le ft s id e a s th e p s o a s
m u s c le is s tr e tc h e d .
• O b tu ra to r sig n r e fle c ts p e lv ic a p p e n d ic itis . T h e re is p e lv ic p a in u p o n in te rn a l
ro ta tio n o f th e rig h t th ig h , c a u s e d b y th e in fla m m a tio n o f o b tu ra to r in te rn u s .
• In D u n p h y sig n p a in is e lic ite d o n a n y a b d o m in a l w a ll m o v e m e n t s u c h a s
c o u g h in g .
*A p o in t c o r re s p o n d in g to th e ju n c tio n o f th e la te ra l a n d m id d le th ir d s o n th e
im a g in a ry lin e d r a w n fr o m th e a n te r io r s u p e r io r ilia c s p in e to th e u m b ilic u s .
in fe c tio n s 172

C h la m y d ia l c e r v ic it is , th e m o s t c o m m o n s e x u a lly tr a n s m itte d
in fe c tio n , is c a u s e d b y w h ic h o f th e fo llo w in g b a c te r ia ?

• C. difficile
• C. perfringens
• C. trachomatis
• C. suis
• C. muridarum

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • C. trachomatis
G o n o rrh e a is a s e x u a lly tr a n s m it te d d is e a s e ( S T D ) . G o n o r r h e a is c a u s e d b y
Neisseria gonorrhoeae , a b a c te r iu m th a t c a n g r o w a n d m u lt ip ly e a s ily in th e
w a r m , m o is t a r e a s o f th e r e p r o d u c tiv e tr a c t, in c lu d in g th e c e r v ix , u te r u s , a n d
fa llo p ia n t u b e s in w o m e n , a n d in th e u r e th r a in w o m e n a n d m e n . T h e b a c te r iu m
c a n a ls o g r o w in th e m o u th , th r o a t , e y e s , a n d a n u s .
It is s e c o n d o n ly to c h la m y d ia l in fe c tio n s in th e n u m b e r o f c a s e s r e p o r te d to
th e C e n te r s fo r D is e a s e C o n t r o l a n d P r e v e n tio n ( C D C ) . T h e e a r ly s y m p to m s o f
g o n o r r h e a o ft e n a r e m ild . S y m p t o m s u s u a lly a p p e a r w it h in 2 to 1 0 d a y s a fte r
s e x u a l c o n ta c t w ith a n in fe c t e d p a r t n e r . G o n o r r h e a is u s u a lly tr e a te d w it h a
s in g le in je c tio n o f c e ftr ia x o n e p lu s d o x y c y c lin e .
W h e n w o m e n h a v e s y m p t o m s , th e fir s t o n e s m a y in c lu d e :
• B le e d in g a s s o c ia te d w ith v a g in a l in t e r c o u r s e
• P a in fu l o r b u r n in g s e n s a tio n s w h e n u r in a tin g
• V a g in a l d is c h a r g e t h a t is y e llo w o r b lo o d y
* ** ln w o m e n , g o n o r r h e a is a c o m m o n c a u s e o f p e lv ic in fla m m a to r y
d is e a s e , w h ic h is a g e n e r a l te r m fo r in fe c tio n o f th e u te r u s , fa llo p ia n tu b e s
a n d o th e r r e p r o d u c tiv e o r g a n s . It is a c o m m o n a n d s e r io u s c o m p lic a tio n o f
s o m e s e x u a lly t r a n s m itt e d d is e a s e s , e s p e c ia lly c h la m y d ia a n d g o n o r r h e a .
M en h a v e s y m p to m s m o r e o fte n th a n w o m e n , in c lu d in g :
• A c u te p u r u le n t u r e th r itis a n d a b u r n in g s e n s a tio n d u r in g u r in a tio n th a t m a y
b e s e v e re
* ** ln m e n , g o n o r r h e a c a n c a u s e e p id id y m itis , a p a in fu l c o n d it io n o f th e
d u c ts a tt a c h e d to th e te s tic le s t h a t m a y le a d to in fe r tility if le f t u n tr e a t e d .
_ 1 . G o n o r r h e a o ft e n o c c u r s t o g e th e r w ith c h la m y d ia a n d s y p h ilis .
2 . C h la m y d ia l c e r v ic itis is th e m o s t c o m m o n s e x u a lly tr a n s m it te d
d is e a s e . It is c a u s e d b y C. trachomatis. It is m o s t o f te n a s y m p to m a tic .
3 . Y o u n g w o m e n w h o c o n tr a c t c h la m y d ia l c e r v ic it is m a y a ls o a c q u ir e
s a lp in g itis ( in fla m m a t io n o f th e fa llo p ia n tu b e s ) .
in fe c tio n s 173

T h e c h a r a c te r is tic le s io n o f s e c o n d a r y s y p h ilis is k n o w n a s:

• ch a n cre
• gum m a
• c o n d y lo m a la ta
• c o n d y lo m a a c u m in a tu m

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r i I • V o lu m e 1 3 • © 2 0 1 7
 • c o n d y lo m a la ta
S y p h ilis is a c o n ta g io u s , s y s t e m ic v e n e r e a l o r c o n g e n it a l d is e a s e c a u s e d b y
th e s p ir o c h e t e T r e p o n e m a p a llid u m . It b e g in s in th e m u c o u s m e m b r a n e s
and q u ic k ly s p re a d s to n e a rb y ly m p h nodes and th e b lo o d s tr e a m .
T r a n s m is s io n o c c u r s p r im a r ily t h r o u g h s e x u a l c o n t a c t d u r in g th e s e c o n d a r y
s ta g e o f in fe c tio n . T r a n s m is s io n fr o m a m o t h e r to h e r f e t u s is p o s s ib le
( s p ir o c h e t e s c a n c r o s s th e p la c e n t a a n d r e s u lt in f e t a l m a lfo r m a tio n ) .
C o n g e n it a l s y p h ilis h a s f e a t u r e s in c lu d in g s a b e r s h in s , s a d d le n o s e , c lu t t o n 's
jo in ts .
T h e r e a r e t h r e e s ta g e s o f s y p h ilis :
_ 1 . P r im a r y : fir m , p a in le s s u lc e r k n o w n a s a c h a n c r e w h ic h a p p e a r s 3
- 6 w e e k s la te r a t t h e s it e o f lo c a l c o n ta c t. T h e lip s a r e th e m o s t
c o m m o n s ite f o r c h a n c r e s to a p p e a r in p r im a r y o r a l s y p h ilis .
2 . S e c o n d a r y ( h ig h ly in fe c tio u s s ta g e ): it o c c u r s 6 w e e k s a f t e r n o n ­
t r e a t m e n t o f p r im a r y s y p h ilis . A m a c u lo p a p u la r r a s h a n d
c o n d y lo m a la ta ( g r a y , f la tt e n e d , w a r t - lik e le s io n s ) a p p e a r o n th e
s k in a n d m u c o s a l s u r fa c e s .
3 . T e r t ia r y : o c c u r s in 3 0 % o f in fe c te d p e r s o n s m a n y y e a r s a f t e r n o n ­
t r e a t m e n t o f s e c o n d a r y s y p h ilis . T h e g u m m a ( f o c a l n o d u la r m a s s )
t y p if ie s t h is s ta g e . M o s t c o m m o n ly o c c u r s o n t h e p a la te a n d
to n g u e . N e u r o lo g ic s y m p t o m s a r e a ls o e v id e n t a t t h is s ta g e .
T e r t ia r y s ta g e is g e n e r a lly n o t c o n ta g io u s .
N o te : T h e p r o g n o s is is g o o d if t r e a t e d e a r ly ; t e r t ia r y s y p h ilis c a u s e s ir r e v e r s ib le
h e a r t fa ilu r e , d e m e n t ia a n d d is a b ility . P a r e n te r a l P e n ic illin G is th e d r u g o f
c h o ic e f o r tr e a t in g a ll s t a g e s o f s y p h ilis .
C o n d y lo m a a c u m in a t u m is a b e n ig n s q u a m o u s c e ll p a p illo m a c a u s e d b y
h u m a n p a p illo m a v ir u s ( H P V ) . It is a s e x u a lly t r a n s m it t e d d is e a s e a n d is
m ost com m on in th e a n o g e n it a l r e g io n . It o ft e n has m u lt ip le le s io n s .
C o n d y lo m a is t r e a t e d b y s u r g ic a l e x c is io n .
in fe c tio n s 174

E n c e p h a litis is m o s t o fte n c a u s e d b y a:

• b a c t e r ia l in fe c tio n
• v ir a l in fe c tio n
• f u n g a l in f e c t io n
• p a r a s itic in fe c tio n

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 - © 2 0 1 7
 • viral infection
V iral e n ce p h a litis is a p a re n c h y m a l in fe ctio n o f th e b rain a lm o s t in v a ria b ly a s s o c ia te d w ith
m en in g ea l in fla m m a tion (m e n in g o e n ce p h a litis) and so m e tim e s w ith s im u lta n e o u s in vo lve m e n t of
th e sp in al co rd (e n ce p h a lo m ye litis). S o m e v iru s e s te nd to in fe ct th e n e rv o u s s yste m . S uch
n e u ra l tro p is m ta k e s s e v e ra l fo rm s : so m e v iru s e s in fe c t s p e c ific ce ll ty p e s (su ch as
o lig o d e n d ro c y te s ), w h ile o th e rs p re fe re n tia lly invo lve p a rtic u la r a re a s o f th e b ra in (su ch a s m edial
te m p o ra l lo b e s o r th e lim b ic s yste m ).
L a te n c y is an im p o rta n t fa c e t o f se ve ra l v ira l in fe c tio n s o f th e C N S (e.g., h e rp e s zo ste r,
p ro g re s s iv e m u ltifo ca l le u k o e n c e p h a lo p a th y ). S yste m ic v ira l in fe ctio n in th e a b se n ce o f d ire ct
e vid e n ce o f vira l p e n e tra tio n in to th e C N S m ay be fo llo w e d by an im m u n e -m e d ia te d d ise ase ,
su ch a s a cu te d is s e m in a te d e n c e p h a lo m y e litis a nd a cu te n e cro tizin g h e m o rrh a g ic
e n ce p h a lo m y e litis . In tra u te rin e vira l infectio n m a y c a u s e c o n g e n ita l m a lfo rm a tio n s , a s o c c u rs w ith
rubella.
A rb o v iru s e s a re a n im p o rta n t c a u s e o f e p id e m ic e n c e p h a litis , e s p e c ia lly in tro p ic a l re g io n s o f the
w orld. H o w e ve r, in u rb an a re as, it is m o s t fre q u e n tly c a u se d b y enteroviruses (c o x s a c k ie v iru s ,
p o lio viru s, a nd e ch o v iru s ). O th e r vira l c a u s e s in clu d e h e rp e s v iru s e s typ e 1 a n d 2, rab ie s, HIV,
V Z V , a nd C M V .
All vira l fo rm s o f e n c e p h a litis h ave s im ila r c lin ica l fe a tu re s. U sua lly, th e acu te illness begins w ith
su d d e n o n s e t o f fe ver, h e a d a ch e , a nd v o m itin g a nd p ro g re s s e s to inclu de s ig n s a nd s y m p to m s o f
m e n in g e a l irrita tio n (stiff n e ck a n d back) a n d n e u ro n a l d a m a g e (d ro w sin e ss, co m a , p a ra lysis,
s e izu re s, a ta xia , tre m o rs, n a u se a , v o m itin g a n d o rg a n ic p sych o se s).
Note: In e n ce p h a litis, in te n se ly m p h o cytic infiltratio n o f b rain tis s u e s a nd th e le p to m e n in g e s
c a u s e s ce re b ra l e d e m a , d e g e n e ra tio n o f th e b ra in 's g a n g lio n ce lls, a nd d iffu se n e rv e cell
d e stru ctio n .
In m eningitis, th e brain a nd s p in a l co rd m e n in g e s b eco m e in fla m e d . It is c a u se d by a n u m b e r of
m icro o rg a n ism s, th e m ost co m m o n in a d u lts b e in g th e N eisseria m eningitidis and
S treptococcus pneum onia. H em ophilus influ en zae is th e m o s t c o m m o n c a u se o f m e n in g itis
in ch ild re n u n d e r th e a g e of tw o . T h e o rg a n is m s are th o u g h t to e n te r th e b o d y th ro u g h th e n ose
a nd th ro at. S ig n s a nd s y m p to m s inclu d e h igh fe v e r, s e v e re h e a d a ch e , a nd stiffn e ss o f th e neck.
Note: W aterhouse-Friderichsen syn d ro m e is an o ve rw h e lm in g , ra p id ly p ro g re ssin g infection
c a u se d b y N e is s e ria m e n in g itid is . It p ro d u c e s se v e re d ia rrh e a , vo m itin g , s e iz u re s , internal
b le ed ing (bilate ral a d ren al h e m o rrh a g e ), low b lo o d p re ssure, sh ock, and o fte n death.
in fe c tio n s 175

A n in fe c tio n is e p id e m ic if:

• it h a s a w o r ld w id e d is tr ib u tio n
• it is c o n s ta n tly p r e s e n t a t m in im a l le v e ls w it h in a p o p u la tio n
• it o c c u r s m o r e fr e q u e n t ly th a n n o r m a l w it h in a p o p u la tio n
• it is h ig h ly c o m m u n ic a b le

M IC R O B IO L O G Y /P A T H O L O G Y H f r d e n t a ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • it h a s a w o r ld w id e d is tr ib u tio n
„ 1 . A n in fe c tio n is e p id e m ic if it o c c u r s m o r e fr e q u e n t ly th a n n o r m a l
w it h in a p o p u la tio n .
2 . A n in fe c tio n is e n d e m ic if it o c c u r s a t m in im a l le v e ls w ith in a
p o p u la tio n .
3 . If a d is e a s e is h ig h ly c o m m u n ic a b le , t h e te r m “c o n t a g io u s ” is
a p p lie d .
In fe c tio u s s ta te s :
• A c u te : s h o r t- te r m a c tiv e in fe c tio n w it h s y m p t o m s
• C h r o n ic : lo n g - te r m a c tiv e in fe c tio n w ith s y m p t o m s
• M a n y in fe c tio n s a r e u n a p p a r e n t o r s u b c lin ic a l a n d c a n o n ly b e d e te c te d
b y d e m o n s t r a t in g a r is e in a n t ib o d y t it e r o r is o la tin g t h e o r g a n is m
• S o m e in f e c t io n s r e s u lt in a la te n t s ta te , a f t e r w h ic h r e a c tiv a tio n o f th e
g r o w th o f t h e o r g a n is m a n d r e c u r r e n c e o f s y m p t o m s m a y o c c u r
• O t h e r in fe c tio n s le a d to a c h r o n ic c a r r ie r s ta te , in w h ic h t h e o r g a n is m s
c o n t in u e to g r o w w it h o r w it h o u t p r o d u c in g s y m p t o m s in th e h o s t
le u k e m ia 176

A c u te ly m p h o b la s tic le u k e m ia e q u a lly a ffe c ts y o u n g c h ild r e n a n d

a d u lts .
T h is a c u te le u k e m ia is th e m o s t r e s p o n s iv e to tr e a tm e n t.

• b o th s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e fir s t s ta te m e n t is tr u e , th e s e c o n d is f a ls e
• th e f ir s t s ta te m e n t is fa ls e , t h e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • the first statem ent is false, the second is true
L e u ke m ia s a re m a lig n a n t n e o p la sm s o f e ith e r lym p ho id o r h e m a to p o ie tic cell o rigin . T h e y a re the
leading cause of cancer death in children under 15 years of age, a nd th e se ve n th m ost
c o m m o n fo rm o f c a n c e r d e a th o ve ra ll. L e u k e m ia s a re p rim a ry d is o rd e rs o f bone m a rro w . T he
e tiolog y of leu ke m ia is unknow n. L eukem ic cells u su a lly spill into the blood, w he re th ey m ay be
seen in large num be rs. Infiltration o f le u kem ic ce lls in th e lym ph nodes, liver, sp le en a nd o th e r
o rg a n s is co m m o n .
A cute leu ke m ia s u sua lly a p p e a r w ith sym p to m s resu ltin g fro m su p p re ssio n o f norm a l m arrow
fu n ctio n . T he se sym p to m s inclu de : a ne m ia , w ith a c co m p a n yin g fa tig u e ; fe ve r, u su a lly reflecting
an infection; a n d /o r b leeding, u sua lly ca use d by th ro m b o cyto p e n ia . C hronic leu kem ias, on the
o th e r h and, can a p p e a r w ith n o n -sp e cific s ym p to m s, in clu d in g fa tig u e , w e ig h t loss, a n e m ia , o r an
a b n orm a l se n sa tio n in th e a b d om en ca use d by sp le no m eg aly.
A cute leu kem ias a re u sua lly fa ta l w ithin w e e ks if left u n tre a te d , w h ile patie nts w ith untreated
ch ro n ic le u ke m ia u sua lly su rvive m uch longer. A cute vs. chronic leukem ia can be
d istin g u ish e d h isto lo g ica lly by th e fa ct th a t acute le u k e m ia s a re c h a ra c te riz e d by th e p re s e n c e of
im m ature, blast cells, w hile chronic le u k e m ia s a re u s u a lly a sso cia te d w ith m ore m ature and
w ell-differen tiated cells. S o m e c h ro n ic le u ke m ia s m ay, h o w e ve r, tra n s fo rm in to an acute
pha se, a so -c a lle d blast crisis.
B e sid e s th e a cu te o r c h ro n ic d e sig n a tio n , le u k e m ia s ca n be su b d iv id e d into th o s e w h ic h are
lym phoblastic (o rig in a tin g fro m a p re c u rs o r o f a B- o r T -ly m p h o c y te ) a n d th o se w h ic h are
m yelogenous (o rig in a tin g fro m a p re c u rs o r o f g ra n u lo c y te s , m o n o c y te s , e ry th ro c y te s , or
m e g a ka ryo cyte s). T h u s, le u ke m ia s ca n be cla ssifie d into fo u r g e n e ra l typ es: a cu te lym p h o b la stic
leu ke m ia (A LL), c h ro n ic lym p h o id le u kem ia (C LL), a cu te m ye lo b la stic le u ke m ia (A M L), and
c h ro n ic m ye lo id le u k e m ia (C M L).
1 . Acute lym phoblastic leukem ia (A LL) is th e fo rm o f a c u te le u k e m ia th a t is th e
m ost responsive to th e ra p y a nd is m ost c o m m o n in ch ild re n . A sso cia te d w ith
e xp o su re to ra d ia tio n a nd ch e m ica ls.
2. Acute m yeloid leukem ia (A M L) is the m ost m a lig n a n t type. It m akes up a b o u t
9 0 % o f a cute le u ke m ia s d ia g n o s e d in a d u lts, it m o re c o m m o n ly a ffe cts m en th an
w o m e n . In cid e n ce in cre a se s w ith age.
3. Chronic lym phocytic leukem ia (C LL) is the lea s t m a lig n a n t type. It is rarely
d ia g n o se d in in d ivid u a ls y o u n g e r th an 40 y e a rs old . It has a ve ry slo w p ro gressio n.
4. Chronic m yelogenous leukem ia (C M L ) is a sso cia te d w ith the P h ila d e lp h ia (Ph)
ch ro m o som e . It is m ore co m m on in m id d le -a g e d and e ld erly individuals.
le u k e m ia 177

T h e p r in c ip a l o r g a n (s ) in v o lv e d in a c u te le u k e m ia is /a r e th e :

• b o n e m a rro w
• b r a in
• lu n g s
• k id n e y s

M IC R O B IO L O G Y /P A T H O L O G Y IM e n t a ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b o n e m a rro w
E a c h o f th e tw o m a jo r t y p e s o f le u k e m ia , m y e lo g e n o u s a n d ly m p h o c y tic , in c lu d e
b o th a c u te a n d c h r o n ic fo r m s .
A c u te e s s e n tia lly r e fe r s to a d is o r d e r o f ra p id o n s e t. In th e a c u te
m y e lo b la s tic le u k e m ia s , th e a b n o r m a l c e lls ( m y e lo b la s ts ) g r o w r a p id ly a n d
d o n o t m a tu r e . M o s t o f t h e s e im m a tu r e c e lls te n d to d ie r a p id ly . In th e a c u te
ly m p h o b la s tic le u k e m ia s , g r o w th o f th e ly m p h o b la s ts a r e n o t a s r a p id a s th a t
o f th e m y e lo b la s tic c e lls . R a th e r , th e c e lls te n d to a c c u m u la te . C o m m o n to b o th
t y p e s o f le u k e m ia is th e ir in a b ilit y to c a r r y o u t th e fu n c tio n s o f h e a lt h y w h it e
b lo o d c e lls . U n tr e a t e d , d e a t h o c c u r s w it h in w e e k s o r a fe w m o n th s .
O th e r im p o r ta n t fe a tu r e s o f a c u te le u k e m ia s :
• A p r e d o m in a n c e o f b la s t c e lls , w h ic h a r e im m a t u r e p r e c u r s o r s o f e ith e r
ly m p h o c y te s ( ly m p h o b la s ts ) , o r g r a n u lo c y te s ( m y e lo b la s ts ) . T h e y d o n o t
n o r m a lly a p p e a r in p e r ip h e r a l b lo o d . W h e n th e y d o , th e y c a n b e r e c o g n iz e d
b y t h e ir la r g e s iz e , a n d p r im itiv e n u c le i ( i.e ., th e n u c le i c o n ta in n u c le o li) .
• A b r u p t o n s e t ( fe w m o n th s ) w ith s u d d e n h ig h fe v e r , w e a k n e s s , m a la is e ,
s e v e r e a n e m ia , a n d g e n e r a liz e d ly m p h a d e n o p a t h y ; b o n e a n d jo in t p a in
c o m m o n in c h ild r e n .
• P rin c ip a l o rg a n in v o lv e d : b o n e m a r r o w ( a lo n g w ith th e s p le e n a n d liv e r) .
• B o n e p a in a n d te n d e r n e s s a r e e x p e r ie n c e d a s a r e s u lt o f m a r r o w e x p a n s io n .
• P e te c h ia e a n d e c c h y m o s is in s k in a n d m u c o u s m e m b r a n e s , h e m o r r h a g e
fr o m v a r io u s s ite s ; b a c te r ia l in fe c tio n s c o m m o n .
•L a b o ra to ry fin d in g s : le u k o c y to s is 3 0 ,0 0 0 -1 0 0 ,0 0 0 p e r c u . m m . w ith
im m a tu r e fo r m s ( m y e lo b la s ts a n d ly m p h o b la s ts ) p r e d o m in a tin g .
• In 7 5 % o f th e c a s e s o f a c u t e ly m p h o c y tic le u k e m ia , th e ly m p h o c y te s a r e
n e ith e r B n o r T c e lls a n d a r e c a lle d “n u ll c e lls .”
R e m e m b e r: A c u te le u k e m ia s o c c u r m o s t o ft e n in c h ild r e n . T h e y e x h ib it a
second peak in c id e n c e a ft e r 6 0 y e a r s o f a g e . L e u k e m ia c a n m o d ify th e
in fla m m a to r y r e a c tio n .
le u k e m ia 178

T h e P h ila d e lp h ia c h r o m o s o m e a n d lo w le v e ls o f le u k o c y te a lk a lin e
p h o s p h a ta s e a r e c o m m o n c h a r a c te r is tic s o f w h ic h t y p e o f le u k e m ia ?

• a c u te m y e lo id le u k e m ia
• a c u te ly m p h o b la s tic le u k e m ia
• c h r o n ic m y e lo id le u k e m ia
• c h r o n ic ly m p h o c y tic le u k e m ia

m ic r o b io l o g y / p a t h o l o g y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • c h r o n ic m y e lo id le u k e m ia
S u r v iv a l r a te s o f le u k e m ia h a v e r is e n d r a m a tic a lly in th e la s t 4 0 y e a r s w ith
im p r o v e m e n ts in d ia g n o s is a n d tr e a tm e n t. T h e h ig h e s t s u r v iv a l r a te s o c c u r in
c h ild r e n w it h th e s o - c a lle d c o m m o n A L L ty p e .
C h r o n ic le u k e m ia s h a v e a s lo w e r o n s e t a n d p r o g r e s s io n th a n a c u te
le u k e m ia s . T h e y a ls o h a v e a lo n g e r, le s s d e v a s ta tin g c lin ic a l c o u r s e th a n
a c u t e le u k e m ia s b u t a r e le s s r e s p o n s iv e to th e r a p e u tic in te r v e n tio n . C h r o n ic
le u k e m ia s a r e c h a r a c te r iz e d b y p r o lif e r a t io n o f ly m p h o id o r h e m a to p o ie tic c e lls
th a t a r e m o r e m a tu r e th a n th o s e o f th e a c u t e le u k e m ia s .
O th e r im p o r ta n t fe a tu r e s o f c h r o n ic le u k e m ia s :
• In s id io u s o n s e t w ith w e a k n e s s a n d w e ig h t lo s s ; d is e a s e m a y b e d e te c te d
d u r in g e x a m in a tio n fo r s o m e o t h e r c o n d itio n , e .g ., a n e m ia , u n e x p la in e d
h e m o r r h a g e s , o r r e c u r r e n t in tr a c ta b le in f e c t io n
• O rg a n in v o lv e m e n t s im ila r to a c u te ty p e : m a s s iv e s p le n o m e g a ly is
c h a r a c te r is tic o f c h r o n ic m y e lo g e n o u s le u k e m ia ; ly m p h n o d e e n la r g e m e n t is
th e m a in p a th o lo g ic fin d in g in th e ly m p h o c y tic ty p e
• P e te c h ia e a n d e c c h y m o s e s , r e c u r r e n t h e m o r r h a g e s , b a c te r ia l in fe c tio n s ;
C L L m a y b e c o m p lic a te d b y a u to im m u n e h e m o ly tic a n e m ia
• L a b o r a to r y fin d in g s : le u k o c y to s is a b o v e 1 0 0 ,0 0 0 p e r c u . m m . w ith m a tu r e
fo r m s ( g r a n u lo c y te s a n d ly m p h o c y te s ) p r e d o m in a tin g ; P h ila d e lp h ia (P h )
c h r o m o s o m e , a n d lo w le v e ls o f le u k o c y te a lk a lin e p h o s p h a ta s e a re
c o m m o n in c h r o n ic m y e lo id le u k e m ia ( C M L )
• M e d ia n s u r v iv a l tim e f o r p a tie n ts w ith c h r o n ic m y e lo g e n o u s le u k e m ia ( C M L )
is fo u r y e a r s w ith d e a th d u e to h e m o r r h a g e o r in fe c tio n ; c h r o n ic ly m p h o c y tic
le u k e m ia ( C L L ) r u n s a v a r ia b le c o u r s e ; o ld e r p a tie n ts m a y s u r v iv e y e a r s
e v e n w ith o u t tr e a tm e n t
N o te : T h e P h C h r o m o s o m e d e s c r ib e s a s p e c if ic tr a n s lo c a tio n b e tw e e n
c h r o m o s o m e s 9 a n d 2 2 . T h e r e s u lt in g a b n o r m a l g e n e ( B C R - A B L ) c o d e s f o r a n
e n z y m e (a t y r o s in e k in a s e ) th a t is h y p o th e s iz e d t o d r iv e th e g r o w th o f C M L
c e lls .
le u k e m ia 179

N o d e fin itiv e c a u s e s h a v e b e e n id e n tifie d fo r le u k e m ia .

P o s s ib le r is k fa c to r s in c lu d e g e n e tic p r e d is p o s it io n , e n v ir o n m e n ta l
e x p o s u r e to c h e m ic a ls a n d r a d ia tio n , a n d v ir u s e s .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s ta te m e n ts a re tru e
N o d e fin itiv e c a u s e s h a v e b e e n id e n tifie d fo r le u k e m ia . P o s s ib le r is k fa c to r s in c lu d e :
• G e n e tic p red is p o s itio n : d o w n s y n d ro m e has a h ig h e r in c id e n c e o f a c u te
le u k e m ia s
• E n v iro n m e n ta l e x p o s u re to
» c h e m ic a ls ( b e n z e n e , s o m e a n ti- c a n c e r d r u g s )
° ra d ia tio n - u s u a lly m y e lo g e n o u s ty p e le u k e m ia s
• V iru se s : H TLV-1 - a d u lt T - c e ll le u k e m ia
° le u k e m ic p a tie n ts h a v e a h ig h a n tib o d y tite r to th e E p s te in -B arr V iru s (E B V )
A b o u t 9 5 % o f p a tie n ts w ith C M L h a v e th e P h ila d e lp h ia (P h ) c h ro m o s o m e , an
a b n o rm a lity in w h ic h th e lo n g a rm o f c h r o m o s o m e 2 2 is tran s lo c a te d , u s u a lly to
c h r o m o s o m e 9. R a d ia tio n a n d c a r c in o g e n ic c h e m ic a ls m a y in d u c e th is c h r o m o s o m a l
a b n o r m a lity . T h is g e n e tic in s ta b ility m a y le a d to a b la s t crisis.
C lin ic a lly , C M L is a d is e a s e w ith s lo w p r o g r e s s io n . T h e fo llo w in g p h a s e s c a n b e
o b se rve d :
1 . C h ro n ic ph ase: th is p h a s e is u s u a lly a s y m p to m a tic . F a tig u e a n d a b d o m in a l
fu lln e s s (a s a r e s u lt o f s e v e r e s p le n o m e g a ly ) a r e th e m o s t c o m m o n c o m p la in ts .
2. A cc e lera ted ph ase: fifty p e r c e n t o f C M L c a s e s p r o g r e s s in to th is p h a s e .
In c r e a s in g a n e m ia , n e w th ro m b o c y to p e n ia a n d a d d itio n a l c y to g e n ic a b n o r m a litie s
in d ic a te p r o g r e s s io n o f th e d is e a s e to w a rd a b la s t c r is is .
3. B last crisis: th e o th e r fifty p e r c e n t a b r u p tly m o v e in to a b la s t c r is is . C lin ic a lly ,
th is la s t p h a s e o f C M L is o f ra p id p ro g r e s s io n w ith lo w s u r v iv a l ra te s .
P a tie n ts in th e c h r o n ic a n d a c c e le r a te d p h a s e s a r e tr e a te d w ith T K in h ib ito r s (i.e .,
G le e v a c ) th a t s p e c ific a lly in h ib it th e a c tiv ity o f a s u b s e t o f ty r o s in e k in a s e s .
P a tie n ts in a b la s t c ris is a r e tr e a te d w ith a h ig h d o s e o f c h e m o th e r a p y fo llo w e d b y
b o n e m a r r o w tr a n s p la n ta tio n .
N o te: T h e P h c h r o m o s o m e is a ls o p r e s e n t in a s m a ll p e r c e n ta g e of a c u te
ly m p h o b la s tic le u k e m ia (A L L ) a n d in a c u te m y e lo g e n o u s le u k e m ia (A M L ).
im m u n o lo g y 180

W h ic h o f th e fo llo w in g im m u n o g lo b u lin s is p r e d o m in a n tly fo u n d in

s a liv a ?

• im m u n o g lo b u lin A
• im m u n o g lo b u lin G
• im m u n o g lo b u lin M
• im m u n o g lo b u lin E

M IC R O B IO L O G Y /P A T H O L O G Y iJ M d e n t a ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • im m u n o g lo b u lin A

I m m u n o g l o b u l i n s ( a n tib o d ie s o r g a m m a g lo b u lin s ) a r e Y - s h a p e d g l y c o p r o t e i n s th a t a r e s y n t h e s i z e d b y p l a s m a
c e l l s . Im m u n o g lo b u lin s h a lt a n tig e n a c tiv ity a n d s h o w a n e x tr a c e llu la r r e s p o n s e to th e in v a d in g m ic ro o rg a n is m s .
T h e b a s ic s tr u c tu r a l u n it o f th e im m u n o g lo b u lin is c o m p o s e d o f t w o h e a v y ( H c h a i n s ) a n d t w o l i g h t ( L c h a i n s )
jo in e d b y d is u lfid e b o n d s . Im m u n o g lo b u lin s a r e d iv i d e d in to fiv e c la s s e s ( I g M , I g G , I g A , I g D , a n d I g E ) o n th e b a s is
o f s tr u c tu r a l v a r ia tio n s .
G e n e r a l p r o p e r t i e s o f i m m u n o g l o b u l i n s a r e a s fo llo w s :

Ig M Ig D Ig G ig E Ig A

S e ru m
im m u n o g lo b u lin 5 -1 0 <1 7 5 -8 5 <1 5 -1 5
<%>
2 3 ( lo n g e s t h a lf-
H a lf - lif e (d a y s ) 5 2 -3 2 -3 6
lif e )

M o le c u la r m a s s 160
900 185 154 190
(k d a )

E p ith e lia l c e lls

B -c e ll p la s m a M a c ro p h a g e s M a s t c e lls a n d
B in d s t o c e lls B c e lls d u r in g
m e m b ra n e a n d n e u tr o p h ils b a s o p h ils
s e c r e tio n

C ro s s e s No
No No Yes No
p la c e n ta

P r in c ip a l
b io lo g ic e ffe c t
P r o d u c e d d u r in g
s e c o n d a ry
im m u n e
re s p o n s e .
D e fe n d s th e
F ir s t a n tib o d y
P r in c ip a l a n tib o d y e x te r n a l b o d y
to re s p o n d and
p r o d u c e d in th e s u r fa c e .
p r o v id e e a r ly P r o v id e s
b o o s te r
d e fe n s e a g a in s t p r o te c tio n a g a in s t S e c r e to r y Ig A
re s p o n s e .
a n tig e n ic p a r a s ite s a n d is p r e s e n t in
C a u s e s B c e ll
c h a lle n g e A c tiv a te s th e causes s a l i v a , te a rs ,
a c tiv a tio n a n d /o r
( b a c te r e m ia ) . c o m p le m e n t a n a p h y la c tic s to o l,
im m u n o r e g u la tio n .
s y s te m . h y p e r s e n s itiv ity c o lo s tr u m ,
A c tiv a te s in te s tin a l,
S tim u la te s ( t y p e l) .
c la s s ic a l r e s p ira to ry , a n d
c o m p le m e n t c h e m o ta x is a n d
o th e r
s y s te m . a c ts a s a n s e c r e tio n s .
o p s o n in
( p r o m o te s k illin g
b y p h a g o c y tic
c e ils ) .
im m u n o lo g y 181

A p a tie n t w ith a tr u e a lle r g y to a m e d ic a tio n is u n k n o w in g ly in je c te d

w ith th e m e d ic a tio n . T h is w ill le a d to :

• lo w le v e ls o f h is ta m in e
• h y p e r g lo b u lin e m ia
• s y s te m ic a n a p h y la x is
• lo c a liz e d a n a p h y la x is

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • s y s t e m ic a n a p h y la x is
W h e n a n a lle r g e n e n t e r s t h e b lo o d s tr e a m it c a n c a u s e w id e s p r e a d a c tiv a tio n
o f th e c o n n e c t iv e tis s u e m a s t c e lls a s s o c ia t e d w it h b lo o d v e s s e ls . T h is c a u s e s
a d a n g e r o u s h y p e r s e n s it iv it y r e a c tio n c a lle d s y s t e m ic a n a p h y la x is . D u r in g
s y s t e m ic a n a p h y la x is , d is s e m in a t e d m a s t- c e ll a c tiv a tio n c a u s e s b o t h a n
in c r e a s e in v a s c u la r p e r m e a b ilit y a n d a w id e s p r e a d c o n s tr ic tio n o f s m o o th
m u s c le . F lu id le a v in g t h e b lo o d c a u s e s th e b lo o d p r e s s u r e t o d r o p d r a s tic a lly ,
a c o n d it io n c a lle d a n a p h y la c t ic s h o c k , a n d t h e c o n n e c t iv e t is s u e s t o s w e ll.
D a m a g e is s u s t a in e d b y m a n y o r g a n s y s t e m s a n d t h e ir f u n c t io n is im p a ir e d .
D e a t h is u s u a lly c a u s e d b y a s p h y x ia tio n d u e t o c o n s t r ic t io n o f t h e a ir w a y s a n d
s w e llin g o f t h e e p ig lo ttis .
Im m e d ia t e tr e a t m e n t fo r a n a p h y la c t ic s h o c k :
• C o n s c io u s p a tie n t
- In je c tio n o f e p in e p h r in e IM o r s u b c u t a n e o u s ly
• U n c o n s c io u s p a tie n t
- In je c tio n o f e p in e p h r in e in tr a v e n o u s ly
“ ‘ M a in ta in a ir w a y (r e m e m b e r A B C 's o f C P R )
Im p o r ta n t: E p in e p h r in e s t im u la t e s th e r e f o r m a t io n o f tig h t ju n c t io n s b e tw e e n
e n d o th e lia l c e lls . T h is r e d u c e s t h e ir p e r m e a b ilit y a n d p r e v e n t s f lu id lo s s fr o m
th e b lo o d , d im in is h in g t is s u e s w e llin g a n d r a is in g b lo o d p r e s s u r e . It a ls o
r e la x e s c o n s t r ic t e d b r o n c h ia l s m o o th m u s c le a n d s t im u la t e s t h e h e a r t.
R e m e m b e r : A n t ih is t a m in e s s u c h a s d ip h e n h y d r a m in e a n d c o r tic o s te r o id s
s u c h a s p r e d n is o n e m a y b e g iv e n to f u r t h e r r e d u c e s y m p t o m s ( a ft e r life s a v in g
m e a s u r e s a n d e p in e p h r in e a r e a d m in is te r e d ) .
N o te : T h e m o s t c o m m o n c a u s e of s y s t e m ic a n a p h y la x is is a lle r g y to
p e n ic illin a n d r e la te d a n tib io tic s .
im m u n o lo g y 182

C e llu la r im m u n ity is im m u n ity m e d ia te d by:

• B - ly m p h o c y te s
• T - ly m p h o c y te s
• b o th B - a n d T - ly m p h o c y te s
• n e it h e r B - n o r T - ly m p h o c y te s

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • T - ly m p h o c y t e s
C e llu la r im m u n ity is im m u n it y m e d ia t e d b y T - ly m p h o c y t e s e it h e r th r o u g h
r e le a s e o f ly m p h o k in e s o r th r o u g h e x e r tio n o f d ir e c t c y to to x ic ity , t r a n s m is s ib le
b y t r a n s f e r o f ly m p h o c y t e s b u t n o t s e r u m ; it c o m p r is e s d e la y e d h y p e r s e n s it iv it y
r e a c tio n s , s y s t e m ic r e s p o n s e to v ir a l a n d m ic r o b ia l in fe c tio n s , c o n ta c t
d e r m a titis , g r a n u lo m a t o u s r e a c tio n s , a llo g r a f t r e je c tio n , a n d g r a f t - v e r s u s - h o s t
r e a c tio n s . It is a s p e c ific a c q u ir e d im m u n it y in v o lv in g T - c e lls . It a c ts to r e s is t
m o s t in t r a c e llu la r p a t h o g e n s ( b a c te r ia a n d v ir u s e s ) .
H u m o r a l im m u n ity ( a ls o c a lle d a n t ib o d y - m e d ia t e d im m u n ity ) is im m u n ity
p r o d u c e d b y t h e a c tiv a tio n o f t h e B -ly m p h o c y te p o p u la tio n . B - c e lls , lik e T -
c e lls , h a v e s u r fa c e r e c e p t o r s w h ic h e n a b le th e m to r e c o g n iz e t h e a p p r o p r ia te
a n tig e n , b u t d o n o t t h e m s e lv e s in t e r a c t t o n e u t r a liz e o r d e s t r o y t h e a n tig e n .
O n r e c o g n itio n o f a n a n tig e n , B - c e lls ta k e u p r e s id e n c e in s e c o n d a r y ly m p h o id
t is s u e ( s u c h a s ly m p h n o d e s a n d s p le e n ) a n d w it h a d d it io n a l s t im u li fr o m T -
h e lp e r c e lls , th e y d iff e r e n tia te in to e it h e r a n a c t iv a t e d p la s m a c e ll o r a m e m o r y
B - c e ll. T h e s h o r t liv e d p la s m a c e lls p r o d u c e a n t ib o d ie s a n d r e le a s e t h e m in to
t h e c ir c u la t io n a t t h e ly m p h n o d e s . T h e m e m o r y B - c e lls c o n t in u e t o p r o d u c e
s m a ll a m o u n t s o f t h e a n tib o d y lo n g a f t e r t h e in fe c tio n h a s b e e n o v e r c o m e .
T h e r e a r e 5 c la s s e s o f a n tib o d ie s . E a c h is c a lle d a n im m u n o g lo b u lin a n d th e n
a llo c a t e d a c o d e le t t e r ( I g G , Ig M , Ig A , Ig E , a n d Ig D ) . Im p o r ta n t: T h e k e y to
h u m o r a l im m u n it y is t h e a b ility o f a n tib o d ie s to r e a c t s p e c if ic a lly w ith
a n tig e n s . T h is ty p e o f im m u n it y p r o v id e s p r o te c tio n a g a in s t e n c a p s u la t e d
b a c t e r ia .
T h e m a in f u n c tio n o f th e im m u n e s y s te m is t o p r e v e n t o r lim it in f e c t io n s b y
m ic r o o r g a n is m s s u c h a s b a c te r ia , v ir u s e s , f u n g i, a n d p a r a s ite s . P r o te c tio n is
p r o v id e d p r im a r ily b y th e c e ll- m e d ia t e d a n d a n t ib o d y - m e d ia t e d ( h u m o r a l) a r m s
o f th e im m u n e s y s te m . T h e o t h e r t w o o t h e r m a jo r c o m p o n e n t s o f t h e im m u n e
s y s te m a r e c o m p le m e n t a n d p h a g o c y te s . T h e c e ll- m e d ia t e d a rm c o n s is t s
p r im a r ily o f T - ly m p h o c y t e s w h e r e a s th e a n t ib o d y - m e d ia t e d a rm c o n s is t s o f B
- ly m p h o c y te s .
im m u n o lo g y 183

O f th e a n a p h y la to x in s , C 3 a is m o re s ta b le a n d m o re p o te n t th a n C 5 a .
O n ly m a s t c e lls h a v e re c e p to r s s p e c if ic fo r C 5 a a n d C 3 a .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e fir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y Ifrd e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • b oth s ta te m e n ts a re fa lse
D u rin g c o m p le m e n t a c tiv a tio n , C 3 a n d C 5 a r e e a c h c le a v e d in to tw o fr a g m e n ts , o f
w h ic h th e la r g e r (C 3 b a n d C 5 b ) c o n tin u e th e p a th w a y o f c o m p le m e n t a c tiv a tio n . T h e
s m a lle r s o lu b le C 3a a n d C 5a fr a g m e n ts a re a ls o p h y s io lo g ic a lly a c tiv e , in c r e a s in g
in fla m m a tio n a t th e s ite o f c o m p le m e n t a c tiv a tio n th ro u g h b in d in g to r e c e p to r s on
s e v e r a l c e ll ty p e s . In fla m m a tio n is a m a jo r c o n s e q u e n c e o f th e in n a te im m u n e
re s p o n s e to in fe c tio n , w h ic h is s o m e tim e s c a lle d th e in fla m m a to r y re s p o n s e . In s o m e
c irc u m s ta n c e s , th e C 3 a a n d C 5 a fr a g m e n ts in d u c e a n a p h y la c tic s h o c k , w h ic h is a n
a c u te in fla m m a to r y r e s p o n s e th a t o c c u r s s im u lta n e o u s ly in tis s u e s th ro u g h o u t th e
b o d y ; th e y a r e th e r e fo r e re fe r re d to a s a n a p h y la to x in s . O f th e a n a p h y la to x in s , C5a
is m o re s ta b le a n d m o re p o te n t th a n C 3 a . P h a g o c y te s , e n d o th e lia l c e lls , a n d m a s t
c e lls h a v e r e c e p to r s s p e c ific fo r C 5 a a n d C 3 a .
T h e a n a p h y la to x in s in d u c e th e c o n tra c tio n o f s m o o th m u s c le a n d th e d e g r a n u la tio n of
m a s t c e lls a n d b a s o p h ils w ith th e c o n s e q u e n t r e le a s e o f h is ta m in e a n d o th e r
v a s o a c tiv e s u b s ta n c e s th a t in c re a s e c a p illa ry p e rm e a b ility . T h e y a ls o h a v e d ire c t
v a s o a c tiv e e ffe c ts o n lo c a l b lo o d v e s s e ls , in c re a s in g b lo o d flo w a n d v a s c u la r
p e r m e a b ility . T h e s e c h a n g e s m a k e it e a s ie r fo r p la s m a p r o te in s to p a s s o u t o f th e
b lo o d in to th e s ite o f a n in fe c tio n .
C 5 a a ls o a c ts d ire c tly o n n e u tr o p h ils a n d m o n o c y te s to in c r e a s e th e ir a d h e r e n c e to
b lo o d v e s s e l w a lls , a n d a c ts a s a c h e m o a ttr a c ta n t to d ir e c t th e ir m ig r a tio n to w a r d
s ite s w h e r e c o m p le m e n t is b e in g fix e d .
_ 1. If th e d e g r a n u la tio n is to o s tr o n g , it c a n c a u s e a lle r g ic r e a c tio n s .
A n a p h y la x is c a u s e d b y th e s e c o m p le m e n t c o m p o n e n ts is le s s c o m m o n
th a n a n a p h y la x is c a u s e d b y T y p e I ( Ig E - m e d ia te d ) h y p e r s e n s itiv ity .
2 . C o m p le m e n t fix a tio n is th e b in d in g o f c o m p le m e n t a s a r e s u lt o f its
in te r a c tio n w ith im m u n e c o m p le x e s (th e c la s s ic a l p a th w a y ) o r p a rtic u la r
s u r fa c e s ( a lte r n a tiv e p a th w a y ) . It is u s e d in d ia g n o s tic te s ts , s u c h a s th e
W a s s e r m a n n te s t (fo r s y p h ilis ) , to d e te c t th e p r e s e n c e o f a s p e c ific
a n tig e n o r a n tib o d y .
3. O n ly Ig M a n d Ig G fix c o m p le m e n t.
im m u n o lo g y 184

A n e x a g g e r a te d Ig E r e s p o n s e to a n e n v ir o n m e n ta l a lle r g e n , a
c o n d it io n k n o w n a s a to p y , m a n ife s ts its e lf in a ll th e fo llo w in g w a y s
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• d e r m a titis
• r h in itis
• ja u n d ic e
• a s th m a

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r i I ‘ V o lu m e 1 3 * © 2 0 1 7
 • ja u n d ic e
A to p ic a lle r g ie s re s u lt fro m a lo c a liz e d e x p r e s s io n o f T y p e I h y p e r s e n s itiv ity
r e a c tio n s . T h e in te r a c tio n o f a n tig e n s (a lle r g e n s ) w ith c e ll-b o u n d Ig E o n th e m u c o s a l
m e m b r a n e s o f th e u p p e r r e s p ir a to r y tr a c t a n d c o n ju n c tiv a l tis s u e s in itia te s a lo c a liz e d
ty p e I h y p e r s e n s itiv ity re a c tio n . M o s t a lle r g y s u ffe r e r s a re s a id to b e a to p ic . A n a to p ic
a lle r g y is o n e w h e r e h e r e d ity p la y s a n im p o r ta n t ro le (i.e ., a lle r g ie s ru n in fa m ilie s ) .
A to p ic in d iv id u a ls a r e g e n e tic a lly p r o g ra m m e d to p r o d u c e a n a b u n d a n c e o f Ig E
( im m u n o g lo b u lin E ) a n tib o d ie s . T h e s e Ig E s s tr o n g ly re a c t a g a in s t a lle r g e n s in th e
e n v ir o n m e n t (p o lle n , m o u ld s , h o u s e h o ld d u s t, e tc .). It is p o s s ib le to b e c o m e a lle r g ic
w ith o u t b e in g a to p ic , b u t a to p y in c r e a s e s th e risk.
N o te: A c h ild w ith o n e p a r e n t w h o h a s s u ffe r e d fro m a lle r g ie s ru n s a 3 0 % r is k o f a ls o
b e c o m in g a lle r g ic . If b o th p a r e n ts h a v e s u ffe r e d fro m a lle r g ie s , th e r is k d o u b le s to
6 0 % . H o w e v e r , a lle r g ie s c a n " ju m p ’1 a g e n e r a tio n .
• A lle rg ic rh in itis: a ls o k n o w n a s h a y fe v e r, it ta k e s p la c e w h e n th e a lle rg e n
in te r a c ts w ith s e n s itiz e d c e lls o f th e u p p e r r e s p ira to r y tra c t. S y m p to m s in c lu d e
c o u g h in g , s n e e z in g , c o n g e s tio n , te a r in g e y e s , a n d r e s p ira to r y d iffic u ltie s .
N o te: T h e p rim a r y m e d ia to r is h is ta m in e , w h ic h is r e le a s e d fro m s e n s itiz e d
m a s t a n d b a s o p h il c e lls .
• A lle rg ic a s th m a : th e a lle r g ic r e a c tio n p r im a r ily a ffe c ts th e lo w e r r e s p ir a to r y tra c t.
It is c o m m o n in c h ild re n a n d is c h a r a c te r iz e d b y s h o r tn e s s o f b r e a th a n d
w h e e z in g .
N o te: S p e c ific Ig E a n tib o d ie s o r n o n s p e c ific in h a le d irr ita n ts p r o v o k e m a s t c e ll
d e g r a n u la tio n ; h is ta m in e , le u k o tr ie n e s ( S R S - A s ), a n d o th e r m e d ia to r s a re
r e le a s e d to c a u s e b r o n c h o s p a s m a n d b r o n c h ia l m u c u s s e c r e tio n .
• A to p ic d e rm a titis : c o m m o n ly r e fe r re d to a s e c z e m a , is a c h r o n ic s k in d is o r d e r
c a te g o r iz e d b y s c a ly a n d itc h in g ra s h e s . E c z e m a is m o s t c o m m o n in in fa n ts , a n d
a t le a s t h a lf o f th o s e c a s e s c le a r b y a g e 3 6 m o n th s . In a d u lts , it is g e n e r a lly a
c h r o n ic o r r e c u r rin g c o n d itio n . A h y p e r s e n s itiv ity re a c tio n o c c u r s in th e s k in ,
c a u s in g c h r o n ic in fla m m a tio n . T h e in fla m m a tio n c a u s e s th e s k in to b e c o m e itc h y
a n d s c a ly .
im m u n o lo g y 185

W h ic h o f th e fo llo w in g is th e m o s t f r e q u e n tly e m p lo y e d d ia g n o s tic

la b o r a to r y te c h n iq u e fo r th e m ic r o s c o p ic d e te c tio n o f a n tig e n s in
tis s u e s e c r e tio n s o r in c e il s u s p e n s io n s ?

• im m u n o flu o r e s c e n c e
• a g g lu tin a tio n

• r a d io im m u n o a s s a y
• p r e c ip ita tio n

• e n z y m e - lin k e d im m u n o s o r b e n t a s s a y

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r i I • V o lu m e 1 3 * © 2 0 1 7
 • im m u n o f lu o r e s c e n c e
In th is t e c h n iq u e , f lu o r e s c e n t d y e s , s u c h a s f lu o r e s c e in a n d r h o d a m in e , a r e
c o v a le n t ly a tt a c h e d t o a n tib o d y m o le c u le s a n d a r e m a d e v is ib le b y u lt r a v io le t
lig h t in th e f lu o r e s c e n c e m ic r o s c o p e . S u c h “ a la b e le d a n t ib o d y ” c a n b e u s e d to
id e n tify a n t ig e n s o n t h e s u r fa c e o f b a c t e r ia .
• R a d io im m u n o a s s a y ( R IA ) : T h is m e th o d is u s e d f o r t h e q u a n t if ic a t io n o f
a n t ig e n s o r h a p t e n s t h a t c a n b e r a d io a c t iv e ly la b e le d .
• E n z y m e - lin k e d - im m u n o s o r b e n t a s s a y ( E L I S A ) : T h is m e th o d can be
used fo r th e q u a n t if ic a t io n of e it h e r a n t ig e n s or a n t ib o d ie s in p a tie n t
s p e c im e n s .
• P r e c ip ita tio n ( P r e c ip it in ) : In t h is te s t, th e a n tig e n is a s o lu tio n . The
a n t ib o d y c r o s s - lin k s a n tig e n m o le c u le s in v a r ia b le p r o p o r t io n s and
a g g r e g a t e s ( p r e c ip ita te s ) fo r m .
• A g g lu tin a tio n : In t h is te s t, th e a n t ig e n is a p a r t ic u la t e ( e . g . , b a c t e r ia a n d
r e d b lo o d c e lls ) . A n t ib o d y ( a g g lu tin in s ) , b e c a u s e it is d iv a le n t o r m u ltiv a le n t,
c r o s s - lin k s t h e a n t ig e n ic a lly m u lt iv a le n t p a r tic le s a n d f o r m s a la ttic e w o r k ,
a n d c lu m p in g ( a g g lu t in a t io n ) c a n b e s e e n . N o te : If t h e a n t ig e n s a r e lo c a t e d
o n th e s u r fa c e o f r e d b lo o d c e lls a n d t h e a d d itio n o f a n t ib o d y le a d s to
c lu m p in g o f th e c e lls , it is c a lle d h e m a g g lu tin a tio n . H e m a g g lu t in a t io n is
th e b a s is f o r b lo o d ty p in g a n d d is t in g u is h in g t h e p r e s e n c e o f A ty p e
a n tig e n o r B ty p e a n tig e n o n th e s u r f a c e o f h u m a n r e d b lo o d c e lls .
im m u n o lo g y 186

W h ic h o f th e fo llo w in g m a jo r p a th w a y s o f c o m p le m e n t a c tiv a tio n is

tr ig g e r e d b y th e p re s e n c e o f in fe c tio n , b u t d o e s n o t in v o lv e a n tib o d y ?

• th e c la s s ic a l p a th w a y
• th e a lt e r n a tiv e p a th w a y
• t h e le c tin p a th w a y
• a ll o f th e a b o v e

M IC R O B IO L O G Y /P A T H O L O G Y i t d e n ta ld ec ks
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e a lte rn a tiv e p a th w a y
T h e c o m p le m e n t s y s te m Is a s y s te m o f s o m e 3 0 s o lu b le a n d c e ll-s u r fa c e p ro te in s th a t
is a m a jo r m e c h a n is m in in n a te a n d a d a p tiv e im m u n ity fo r id e n tify in g a n d e lim in a tin g
p a th o g e n s a n d th e ir p ro d u c ts . A s a re s u lt o f c o m p le m e n t a c tiv a tio n , p a th o g e n s
b e c o m e c o a te d w ith c o m p le m e n t c o m p o n e n ts , w h ic h c a n e ith e r k ill th e p a th o g e n
d ire c tly o r fa c ilita te its e n g u lfm e n t a n d d e s tru c tio n b y p h a g o c y te s . Im p ortant:
C o m p le m e n t a c tiv a tio n is a fe a tu re of ty p e III h y p e rs e n s itiv ity re a c tio n s .
T h e re a re th ree m a jo r p ath w a y s o f c o m p le m e n t a c tiv a tio n :
• T h e c la s sic a l p ath w a y , it is a c tiv a te d b y a n tib o d y b o u n d to a n tig e n , a n d in v o lv e s
c o m p le m e n t c o m p o n e n ts C l , C 4 , a n d C 2 in th e g e n e r a tio n o f th e c la s s ic a l C 3 a n d
C 5 c o n v e rta s e s
• T h e a lte rn a tiv e p a th w a y , it is trig g e re d b y th e p re s e n c e o f in fe c tio n b u t d o e s n o t
in v o lv e a n tib o d y
• T h e lectin p ath w a y, it is a c tiv a te d b y th e b in d in g o f a m a n n o s e - b in d in g le c tin
p re s e n t in b lo o d p la s m a to m a n n o s e - c o n ta in in g p e p tid o g ly c a n s o n b a c te ria l
s u rfa c e s
Key p o in t: T h e a lte rn a tiv e a n d le c tin p a th w a y s a re a c tiv a te d in a n a n tib o d y
in d e p e n d e n t fa s h io n a n d a p p e a r to b e o f m a jo r im p o rta n c e in h o s t d e fe n s e a g a in s t
in v a d in g m ic ro o rg a n is m s .
Im p o rtan t: A lth o u g h d iffe rin g in h o w th e y a re trig g e r e d a n d in th e fir s t fe w r e a c tio n s in
th e c a s c a d e , all o f th e p a th w a y s lead to C 3 a c tiv a tio n , th e d e p o s itio n o f C 3 b o n th e
p a th o g e n 's s u rfa c e a n d th e re c ru itm e n t o f s im ila r e ffe c to r m e c h a n is m s fo r p a th o g e n
d e s tru c tio n .
N ote: T h e u n u s u a l fe a tu r e of C 3 th a t u n d e rlie s its u n iq u e a n d p o te n t fu n c tio n is a h ig h
e n e rg y th io e s te r b o n d w ith th e g ly c o p ro te in .
1 . C yto ly s is re fe rs to th e ly s is o f b a c te ria o r o f c e lls s u c h a s tu m o r o r red
b lo o d c e lls b y in s e rtio n o f th e m e m b ran e a tta c k c o m p lex d e riv e d fro m
c o m p le m e n t a c tiv a tio n .
2. C h a r a c te r is tic s o f C l :
• It is a c o n s titu e n t o f th e c la s s ic c o m p le m e n t p a th w a y
• C o m p o s e d o f th re e p ro te in s ( C lq , C l r , a n d C I s )
• C a lc iu m is re q u ire d fo r a c tiv a tio n o f C l
im m u n o lo g y 187

In p a s s iv e im m u n it y , a n tib o d ie s a re p r e fo r m e d in a n o th e r h o s t.
P a s s iv e im m u n ity la s ts a s lo n g a s a c tiv e im m u n ity .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta t e m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e fir s t s ta te m e n t is tr u e , t h e s e c o n d is fa ls e
A c q u ir e d im m u n it y o c c u rs n a t u r a lly a n d a r tif ic ia lly . It c a n be a c tiv e o r
p a s s iv e .
N a tu r a lly :
• A c tiv e : p e r s o n is e x p o s e d to a n a n tig e n a n d t h e b o d y p r o d u c e s
a n tib o d ie s .
• P a s s iv e : a n t ib o d ie s ( I g G ) p a s s e d fr o m m o th e r to fe tu s d u r in g p r e g n a n c y
a n d Ig A p a s s e d fr o m m o th e r to n e w b o r n d u r in g b r e a s t- fe e d in g . T h e s e
a n t ib o d ie s d is a p p e a r b e tw e e n 6 a n d 1 2 m o n t h s o f a g e .
A r tif ic ia l:
• A c tiv e : v a c c in a tio n w ith k ille d , in a c tiv a te d , or a tt e n u a t e d b a c t e r ia or
to x o id .
• P a s s iv e : in je c tio n o f im m u n e s e r u m o r g a m m a - g lo b u lin .
1 . In a c tiv e im m u n ity , t h e h o s t a c t iv e ly p r o d u c e s a n im m u n e
r e s p o n s e c o n s is t in g o f a n t ib o d ie s a n d a c t iv a t e d h e lp e r a n d
c y to to x ic T - ly m p h o c y te s . T h e m a in a d v a n t a g e is t h a t th e
r e s is ta n c e is lo n g -te r m ( y e a r s ) ; t h e m a jo r d is a d v a n t a g e is its s lo w
o n s e t.
2 . In p a s s iv e im m u n ity , a n t ib o d ie s a r e p r e f o r m e d in a n o t h e r h o s t. It is
n o t a s p e r m a n e n t a n d d o e s n o t la s t a s lo n g a s a c t iv e im m u n ity
( i.e ., t e t a n u s a n d s n a k e v e n o m ) . T h e m a in a d v a n t a g e is t h e
im m e d ia t e a v a ila b ilit y o f a n tib o d ie s ; t h e m a jo r d is a d v a n t a g e is th e
s h o r t d u r a tio n ( m o n th s ) .
im m u n o lo g y 188

A s m a ll m o le c u le , n o t a n tig e n ic b y its e lf, c a n re a c t w ith

a n tib o d ie s is c a lle d a (a n ):

• e p ito p e
• h a p te n
• p la s m id
• im m u n o g e n

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • h a p te n
H a p t e n s ( in c o m p le t e im m u n o g e n s ) h a v e a n t ig e n ic d e t e r m in a n t s , b u t a r e to o
s m a ll to e lic it t h e fo r m a t io n o f a n t ib o d ie s b y th e m s e lv e s . H a p te n s c a n b e
m a d e im m u n o g e n ic b y a t t a c h m e n t t o a c a r r ie r m o le c u le , s u c h a s a p r o te in .
F o r e x a m p le , d in it r o p h e n o l c o n ju g a t e d to b o v in e s e r u m a lb u m in is a n
im m u n o g e n fo r th e d in it r o p h e n o l h a p te n . N o te : H a p te n s a re not
im m u n o g e n ic b e c a u s e t h e y c a n n o t a c tiv a te h e lp e r T - c e lls .
Im p o r ta n t: A n t ib o d y p r o d u c tio n in v o lv e s a c tiv a tio n o f B - ly m p h o c y t e s b y th e
h a p te n a n d h e lp e r T - ly m p h o c y t e s b y t h e c a r r ie r .
R e m e m b e r t h a t a n a n tig e n is a n y s u b s t a n c e th a t c a n s p e c if ic a lly b in d
a n t ib o d ie s o r t h e T - c e ll a n tig e n r e c e p to r . T h o s e a n t ig e n s t h a t c a n s t im u la t e a n
im m u n e re s p o n s e a re im m u n o g e n s ; th e r e f o r e a ll im m u n o g e n s a r e
a n tig e n s , b u t n o t a ll a n tig e n s a r e im m u n o g e n s . A la r g e v a r ie t y o f b io lo g ic a l
m o le c u le s ( i.e ., p r o te in s , c a r b o h y d r a t e s , lip id s a n d n u c le ic a c id s ) a r e a b le to
b in d to a n tib o d ie s , w h ile o n ly p e p tid e s a r e r e c o g n iz e d b y T - c e lls . In o r d e r t o b e
im m u n o g e n ic , a n t ig e n s m u s t b e f o r e ig n , w ith a h ig h m o le c u la r w e ig h t, a
c e r ta in d e g r e e o f c h e m ic a l c o m p le x ity , a n d , f o r T - c e ll a n t ig e n s m u s t b e a b le to
in te r a c t w ith th e h o s t's m a jo r h is t o c o m p a t ib ilit y c o m p le x ( M H C ) .
1 . P la s m id s a r e e x t r a c h r o m o s o m a l g e n e t ic s t r u c t u r e s t h a t c a n
r e p lic a te in d e p e n d e n tly w it h in a b a c te r ia l c e ll. T h e s e m o le c u le s o f
D N A a r e s e p a r a t e fr o m t h e b a c te r ia l c h r o m o s o m e s a n d d e t e r m in e
t r a it s n o t e s s e n tia l f o r t h e v ia b ility o f t h e o r g a n is m b u t in s o m e w a y
c h a n g e t h e o r g a n is m 's a b ilit y to a d a p t. R ( r e s is ta n c e ) f a c t o r is a n
e x a m p le . M o s t a n t ib io t ic r e s is t a n c e in b a c t e r ia is c a u s e d b y g e n e s
t h a t a r e c a r r ie d o n p la s m id s . P la s m id s m a y b e p a s s e d fr o m o n e
b a c te r iu m to a n o th e r , a n d th e y a r e r e p lic a te d in la te r g e n e r a t io n s o f
a n y b a c te r iu m c a r r y in g th e m .
2 . E p ito p e is t h e s p e c if ic p o r tio n o f a n a n tig e n t o w h ic h t h e a n t ib o d y
b in d s .
im m u n o lo g y 189

W h ic h o f th e fo llo w in g ty p e s o f im m u n it y is c o n fe r r e d b y tr a n s fe r r in g
ly m p h o id c e lls fr o m a n a c tiv e ly im m u n iz e d d o n o r to a n a iv e o r
im m u n o c o m p r o m is e d h o s t?

• a c q u ir e d im m u n ity
• h u m o r a l im m u n ity
• p a s s iv e im m u n it y
• a c tiv e im m u n ity
• a d o p tiv e im m u n it y

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • a d o p tiv e im m u n ity
N atural o r in n ate im m u n ity is im m u n ity th a t o c c u r s n a tu r a lly a s a r e s u lt o f a p e r s o n 's
g e n e tic c o n s titu tio n o r p h y s io lo g y a n d d o es n ot a ris e fro m a p r e v io u s in fe c tio n o r
v a c c in a tio n . T h is is a c h ie v e d th r o u g h p h y s ic a l b a r r ie r s a n d p r e fo r m e d , n o n - s p e c ific
s u b s ta n c e s a n d m e d ia to r s th a t e lim in a te a b r o a d s p e c tr u m o f p a th o g e n s . A n
e x a m p le is th e p h a g o c y to s is o f b a c te r ia b y n e u tro p h ils a n d m a c r o p h a g e s .
In c o n tras t to a c q u ir e d im m u n ity , n a tu ra l im m u n ity :
• Is n o n s p e c ific : a c q u ir e d im m u n ity is s p ec ific
• D o es n o t im p ro ve a fte r e x p o s u r e to th e o rg a n is m : a c q u ir e d im m u n ity im p ro ve s
upon rep eated ex p o s u re
• P r o c e s s e s h a v e no m e m o ry : a c q u ir e d im m u n ity is c h a r a c te r iz e d b y lo n g -te rm
m e m o ry
1. A c q u ire d im m u n ity o c c u r s a fter e x p o s u re to a n a n tig e n , im p ro ve s
u p o n r e p e a te d e x p o s u r e , a n d is s p e c ific . It is m e d ia te d b y a n tib o d ie s
a n d b y T - ly m p h o c y te s ( h e lp e r a n d c y to to x ic T -c e lls ) . T h e c e lls
r e s p o n s ib le fo r a c q u ir e d im m u n ity h a v e lo n g -te rm m e m o ry fo r a
s p e c ific a n tig e n .
2. H y p e rs e n s itiv ity is a n e x a g g e ra te d im m u n o lo g ic a l r e s p o n s e u p o n re ­
e x p o s u r e to a s p e c ific a n tig e n (i.e ., p o s itiv e s k in te s t a fte r h a v in g a
d is e a s e ) .
3. H u m o ra l im m u n ity is m e d ia te d b y a n tib o d ie s p r o d u c e d th r o u g h th e
h u m o r a l im m u n e r e s p o n s e . It c a n b e tr a n s fe r r e d th r o u g h s e ru m
c o n ta in in g s p e c ific a n tib o d ie s .
4. P a s s iv e im m u n ity is c o n fe r r e d b y a n tis e r u m o r o th e r a n tib o d ie s . It
g r a n ts im m e d ia te p r o te c tio n , b u t its p ro te c tio n is o n ly te m p o r a r y .
5. A c tiv e im m u n ity is a c q u ir e d b y in tro d u c in g a n a n tig e n w h ic h in tu rn
p r o v o k e s a n a d a p tiv e im m u n e re s p o n s e .
6. A d o p tiv e im m u n ity is c o n fe r r e d b y tr a n s fe r r in g ly m p h o id c e lls fro m a n
a c tiv e ly im m u n iz e d d o n o r to a n a iv e o r im m u n o c o m p r o m is e d h o s t.
im m u n o lo g y 190

T h e c o m p le m e n t s y s te m is a g ro u p o f p la s m a p r o te in s th a t a tta c k
p a th o g e n s .
T h e s e p r o te in s a re p r im a r ily s y n th e s iz e d b y th e k id n e y .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y t^ d e n ta ld e c k s
P a rt I • V o lu m e 13 * © 2 0 1 7
 • th e first statem ent is true, the second is false
* * * T h is s e c o n d s ta te m e n t is false; c o m p le m e n t p r o te in s a re s y n th e s iz e d m a in ly b y th e
liver. S o m e a re m a d e in m a c r o p h a g e s . Note: C l is m a d e in G l e p ith e liu m .
T h e im m u n e s y s te m is c o m p o s e d o f c e lls a n d s o lu b le s u b s ta n c e s . T h e m a jo r c e lls of
th e im m u n e s y s te m a re th e w h ite b lo o d c e lls ( m a c r o p h a g e s , n e u tr o p h ils , a n d
ly m p h o c y te s ) . S o lu b le s u b s ta n c e s a re m o le c u le s th a t a re n o t c o n ta in e d in c e lls b u t
a re d is s o lv e d in a liq u id , s u c h a s p la s m a . T h e m a jo r s o lu b le s u b s ta n c e s a re
a n tib o d ie s , c o m p le m e n t p ro te in s , a n d c y to k in e s . T h e s o lu b le s u b s ta n c e s a c t as
m e s s e n g e rs to a ttra c t a n d a c tiv a te o th e r c e lls .
T h e com plem ent system is a s y s te m o f s o m e 3 0 s o lu b le a n d c e ll-s u r fa c e p ro te in s
th a t is a m a jo r m e c h a n is m in in n a te a n d a d a p tiv e im m u n ity fo r id e n tify in g a n d
e lim in a tin g p a th o g e n s a n d th e ir p ro d u c ts .
T h e re a re three m ajor pathw ays o f c o m p le m e n t a c tiv a tio n :
• T h e classical pathway, is in itia te d in th e in n a te im m u n e re s p o n s e b y th e b in d in g
o f C -reactive protein to b a c te ria l s u rfa c e s , a n d in th e a d a p tiv e im m u n e re s p o n s e
b y th e b in d in g o f antibodies to p a th o g e n s u rfa c e s . T h e c o m p le m e n t c o m p o n e n ts
th a t a re u n iq u e ly u s e d b y th e c la s s ic a l p a th w a y a re th e b in d in g p ro te in C l , th e
p ro te a s e C 2 , a n d th e th io e s te r -c o n ta in in g p ro te in C 4 .
• T h e alternative pathw ay, is trig g e r e d b y c h a n g e s in th e lo c a l p h y s ic o c h e m ic a l
e n v iro n m e n t th a t a re c a u s e d b y th e c o n s titu e n ts o f s o m e b a c te ria l s u rfa c e s . T h is
p a th w a y a c ts a t th e earliest tim es d u rin g in fe c tio n .
• T h e lectin pathway, is in itia te d b y th e m annose-binding lectin in p la s m a , w h ic h
b in d s to c a r b o h y d r a te s fo u n d on b a c te ria l c e lls a n d o th e r p a th o g e n s . T h is p a th w a y
is in d u c e d b y in fe c tio n a n d c o n trib u te s to in n a te im m u n ity .
T h e c o m p le m e n t c o m p o n e n t C5 is s tru c tu r a lly s im ila r to C 3 b u t la c k s th e th io e s te r
b o n d a n d h a s a d iffe r e n t fu n c tio n . It's fu n c tio n is to in itia te th e fo r m a tio n o f a
m em brane-attack com plex, w h ic h c a n m a k e h o le s in th e m e m b r a n e s o f b a c te ria l
p a th o g e n s a n d e u k a r y o tic c e lls . In s u c c e s s io n , C6 a n d C7 b in d to C 5 b - in te ra c tio n s
th a t e x p o s e a h y d r o p h ilic s ite in C 7 , w h ic h in s e rts in to th e lip id b ila y e r. W h e n C8 b in d s
to C 5 b a h y d ro p h o b ic s ite in C 8 is e x p o s e d a n d , o n in s e rtio n in to th e m e m b ra n e , th is
p a rt of C 8 in itia te s th e p o ly m e riz a tio n o f C9, th e c o m p o n e n t th a t fo r m s th e
tr a n s m e m b r a n e p o re s .
im m u n o lo g y 191

E a c h o f t h e fo llo w in g a re a s s o c ia te d w ith a n a n a p h y la c tic

h y p e r s e n s it iv ity r e a c tio n E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• h is ta m in e
• h e p a r in

• p la te le t- a c tiv a tin g fa c to r s
• s e r o to n in
• d o p a m in e

M IC R O B IO L O G Y /P A T H O L O G Y 1 * d e n ta l decks
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 d o p a m in e
R e m e m b er:
1. A n a p h yla c tic s h o c k ( a n a p h y la x is ) is p h y s io lo g ic a l s h o c k re s u ltin g fr o m a n
a n a p h y la c tic h y p e r s e n s itiv ity r e a c tio n (fo r e x a m p le , to p e n ic illin o r b e e b ite s ). In
s e v e r e c a s e s , d e a th c a n r e s u lt w ith in m in u te s . T h is a n a p h y la c tic r e a c tio n in v o lv e s
th e d e g r a n u la tio n o f m a s t c e lls a n d th e r e le a s e o f h is ta m in e , h e p a r in , p la te le t­
a c tiv a tin g fa c to r s , S R S - A s , a n d s e r o to n in in to th e b lo o d s tre a m .
2. H is ta m in e is r e s p o n s ib le fo r th e p r in c ip a l s y m p to m s o f a n ap h y la x is .
3. In a sth m a , th e a lle r g e n r e a c tio n o c c u r s in th e b ro n c h io le s o f th e lu n g s . T h e m o s t
im p o r ta n t p r o d u c ts r e le a s e d fro m th e m a s t c e ll a re th e S R S - A s ( th e y a r e th e
p r im a ry m e d ia to r s o f a s th m a ) , w h ic h c a u s e s s p a s m o f th e b ro n c h io la r s m o o th
m u s c le .
P ro s ta g la n d in s a n d le u k o trie n e s a re lip id s s y n th e s iz e d fro m fa tty a c id s . T h e y a re
k n o w n a s e ic o s a n o id s . M a s t c e lls s y n th e s iz e a n d s e c re te th e s e in fla m m a to r y
m e d ia to r s in r e s p o n s e to a c tiv a tio n .
O n c e a r a c h id o n ic a c id is g e n e r a te d ( b y in fla m m a to r y c e lls a n d in ju r e d tis s u e s ) , it is
m e ta b o liz e d th ro u g h tw o p a th w a y s :
1. C y c lo o x y g e n a tio n : p r o d u c e s p r o s ta g la n d in s a n d th r o m b o x a n e s .
2. L ip o x y g e n a tio n : p r o d u c e s le u k o tr ie n e s a s w e ll a s H E T E s a n d d iH E T E s .
T h e le u k o tr ie n e s h a v e a c tiv itie s s im ila r to th o s e o f h is ta m in e , b u t a r e m o r e th a n 10 0
tim e s m o re p o te n t o n a m o le c u le - fo r - m o le c u le b a s is . T h e tw o k in d s o f m e d ia to r a re
th e r e fo r e c o m p le m e n ta r y . H is ta m in e p r o v id e s a r a p id r e s p o n s e w h ile th e m o r e
p o te n t le u k o trie n e s a r e b e in g m a d e . In th e la te r s ta g e s o f a lle r g ic r e a c tio n s ,
le u k o tr ie n e s a r e p r in c ip a lly r e s p o n s ib le fo r in fla m m a tio n , s m o o th m u s c le c o n tr a c tio n ,
c o n s tr ic tio n o f a irw a y s , a n d th e s e c r e tio n o f m u c u s fr o m m u c o s a l e p ith e liu m . N o te:
L e u k o trie n e s C 4, D 4, a n d E 4 a re c o lle c tiv e ly k n o w n a s s lo w -re a c tin g s u b s ta n c e s of
a n a p h yla x is (S R S - A s ) a n d a re r e s p o n s ib le fo r th e d e v e lo p m e n t o f m u c h o f th e
c lin ic a l s y m p to m a to lo g y a s s o c ia te d w ith a lle r g ic -ty p e r e a c tio n s .
im m u n o lo g y 192

Ig M , Ig A , a n d Ig G a r e th e m a in a n tib o d ie s p r e s e n t in b lo o d , ly m p h ,
a n d th e in te r c e llu la r flu id in c o n n e c tiv e tis s u e s .
Ig A is a ls o m a d e in th e ly m p h o id tis s u e s u n d e r ly in g m u c o s a a n d th e n
s e le c tiv e ly tr a n s p o r te d a c r o s s th e m u c o s a l e p ith e liu m to b in d
e x tr a c e llu la r p a th o g e n s a n d th e ir t o x in s o n th e m u c o s a l s u rfa c e s .

• b o th s t a te m e n ts a r e tr u e
• b o t h s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is f a ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • both statem ents are true
W h e re a s IgM , IgG , and m o n o m e ric IgA p ro v id e a n tig e n -b in d in g fu n c tio n s w ith in flu id s and
tis s u e s of th e b ody, d im e ric IgA (secretory IgA) p ro te c ts th e s u rfa c e s o f m u co sa l e p ith e lia
th a t c o m m u n ic a te w ith th e e x te rn a l e n v iro n m e n t and are p a rtic u la rly v u ln e ra b le to
in fe ctio n . T h e s e e p ith e lia inc lu d e th e lin in g s of th e g a s tro in te s tin a l tra c t, th e e ye s, nose,
th ro a t, th e re s p ira to ry , u rin a ry, a nd g e n ita l tra c ts , a nd th e m a m m a ry gla n d s.
M o n o m eric IgA c irc u la te s in th e b lo o d a n d is p ro d u c e d in th e b o n e m a rro w by p la s m a
ce lls d e riv e d fro m B c e lls a c tiv a te d in s y s te m ic lym p h no d e s o r th e sp le e n . In c o n tra st,
d im eric IgA is s e c re te d in m u c o s a l tis s u e s by p la s m a ce lls th a t d e riv e fro m B cells
a c tiv a te d in th e m u co sa l im m u n e s yste m . In d ivid u a l p la s m a ce lls m a ke e ith e r m o n o m e ric
o r d im e ric IgA, a nd in g e n e ra l th e a n tig e n s th a t s tim u la te p ro d u c tio n of th e tw o fo rm s do
no t overlap.
S ecretory IgA (d im e ric IgA) h as little c a p a c ity or o p p o rtu n ity to a c tiv a te c o m p le m e n t o r a ct
as an opsin, a nd it c a n n o t in d u c e a s ta te of in fla m m a tio n . In ste a d it has e v o lv e d to be a
n o n -in fla m m a to ry im m u n o o g lo b u lin th a t lim its th e a c c e s s o f p a th o g e n s , c o m m e n s a ls , and
fo o d p ro d u c ts to m u co sa l s u rfa c e s in a m a n n e r th a t a v o id s u n n e c e s s a ry d a m a g e to th e se
d e lic a te a nd v ita l tissues.
Rem em ber: IgA is one of the m ost p re va len t h u m o ra l a n tib o d ie s (s e c o n d o n ly to IgG)
p ro d u c e d by th e body.
1. IgM is a lw a y s th e firs t a n tib o d y to be s e c re te d in th e im m u n e re s p o n s e (IgD
a n tib o d y is a ls o m ade, b u t in n e g lig ib le a m o u n ts ).
2. D uring th e s e c o n d a ry h u m o ra l im m u n e re s p o n s e (a se c o n d e x p o s u re to th e
s a m e antig e n , fo r e x a m p le w h e n a perso n re ce ive s a th ird im m u n iz a tio n w ith
te ta n u s to x o id ), a m ore ra p id a nd g re a te r re sp o n se e n su e s, w h ich is
p re d o m in a n tly co m p o s e d of IgG , not IgM , as th e m a jo r c la s s o f a n tib o d y.
3. As th e s e v e rity of an infection in c re a s e s (fo r e xa m p le , p e rio d o n ta l disease),
th e re is an in c re a s e in p la s m a c e lls th a t p ro d u c e IgG.
4. T h e m o s t im p o rta n t fu n c tio n o f IgG a n tib o d ie s is to fa c ilita te th e e n g u lfm e n t
a nd d e s tru c tio n o f e x tra c e llu la r m ic ro o rg a n is m s and to x in s by p h a g o cyte s.
5. N o fu n c tio n is y e t know n fo r IgD o th e r th a n as a m e m b ra n e receptor.
6. IgE is th e im m u n o g lo b u lin re s p o n s ib le fo r a lle rg ic o r a n a p h y la c tic re a c tio n s .
im m u n o lo g y 193

In d iv id u a ls w ith w h ic h b lo o d g ro u p a r e c o n s id e r e d to b e u n iv e rs a l
d o n o rs ?

• A

•B
• O

• AB

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 •0
T y p e A B in d ic a t e s b o th a n t ig e n s ( a llo a n tig e n s ) ; ty p e O t h e a b s e n c e o f b o th .
C o r r e s p o n d in g a n tib o d ie s , a n ti- A , a n d a n ti- B a g g lu t in in s , c a n b e f o u n d in th e
p la s m a o f t y p e O b lo o d . T h e p la s m a c o m p o n e n t s o f ty p e A a n d ty p e B b lo o d
a r e , r e s p e c tiv e ly , d e v o id o f a n ti- A a n d a n ti- B a g g lu t in in s ; b o th a g g lu t in in s a r e
a b s e n t fr o m ty p e A B b lo o d p la s m a .
B o t h t h e A B O a s w e ll a s R h ( R h e s u s ) a n t ig e n s h a v e to b e c o n s id e r e d d u r in g
a b lo o d t r a n s f u s io n . If b lo o d t h a t w a s in c o r r e c t ly c r o s s - m a t c h e d is t r a n s fu s e d ,
it w ill c a u s e a g g lu tin a tio n o f th e d o n o r 's e r y th r o c y te s .
B lo o d G r o u p s A n tig e n s ( A g g lu tin o g e n s ) A n t ib o d ie s ( A g g lu t in in s )
o n E ry th ro c y te s in P la s m a

0 A nti-A and A nti-B

-
(U n iv ersal D onors)

A A A nti-B

B B A nti-A

AB A an d B
-
(U niversal Recipients)
im m u n o lo g y 194

T y p e II h y p e r s e n s itiv ity r e a c tio n s r e s u lt fr o m th e b in d in g o f a n tig e n to

a n tig e n -s p e c ific Ig E b o u n d to its F c re c e p to r , p r in c ip a lly o n m a s t
c e lls .
T y p e III h y p e r s e n s itiv ity r e a c tio n s a r e c a u s e d b y s m a ll s o lu b le
im m u n e c o m p le x e s fo r m e d b y s o lu b le p ro te in a n tig e n s b in d in g to th e
Ig G m a d e a g a in s t th e m .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is f a ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • th e firs t s ta te m e n t is fa ls e , th e se c o n d is tru e
C la s s if i c a t i o n o f H y p e r s e n s i t iv i t y R e a c t io n s

Type 1 T y p e II T y p e III T y p e IV

Im m u n e Ig E Ig G Ig G T h I c e lls T n 2 c e lls CTL

re a c t a n t

A n tig e n S o lu b le C e l l - o r m a trix C e l l- s u r fa c e S o lu b le S o l u b le S o l u b le C e ll-

a n ti g e n asso ciated re c e p t o r a n ti g e n a n tig e n a n tig e n a sso ciated
a n tig e n a n ti g e n

E ff e c to r M a s t c e ll C o m p le m e n t. A n ti b o d y C o m p le m e n t M a c ro p h a g e E o s in o p h il C y to to x ic ity
m e c h a n is m a c ti v a tio n F c R * c e lls a l te rs P h a g o c y te s a c ti v a tio n a c tiv a t io n
(p h a g o c y te s . s i g n a l in g
N K c e lls )

E x a m p le o f A lle rg ic S o m e d ru g C h ro n i c S crum sick ne ss C o n ta c t C h r o n ic C o ntact

hy p e rse n si­ rh in iti s a lle rg ie s u rtic a r ia A r th u s re a c t io n d e r m a t iti s . a s th m a . d e r m a t iti s
tiv ity a s th m a . tu b e r c u lin c h ro n ic
re a c tio n s y s te m i c rv u c tio n a ll e r g ic
a n a p h y la x i s rh in iti s

• T y p e I h y p e r s e n s itiv ity r e a c tio n s re s u lt fro m th e b in d in g o f a n tig e n to a n tig e n -

s p e c ific Ig E b o u n d to its F c r e c e p to r , p r in c ip a lly o n m a s t c e lls . T h is in te r a c tio n
c a u s e s th e d e g r a n u la tio n o f m a s t c e lls a n d th e re le a s e o f in fla m m a to r y m e d ia to r s .
• T y p e II h y p e r s e n s itiv ity r e a c tio n s a re c a u s e d b y s m a ll m o le c u le s th a t b o n d
c o v a le n tly to c e ll-s u r fa c e c o m p o n e n ts o f h u m a n c e lls , p r o d u c in g m o d ifie d
s tr u c tu r e s th a t a re p e r c e iv e d a s fo r e ig n b y th e im m u n e s y s te m . T h e B c e ll
r e s p o n s e to th e s e n e w e p ito p e s p r o d u c e s Ig G , w h ic h o n b o n d in g to th e m o d ifie d
c e lls c a u s e s th e ir d e s tr u c tio n th r o u g h c o m p le m e n t a c tiv a tio n a n d p h a g o c y to s is .
• T y p e III h y p e r s e n s itiv ity r e a c tio n s a re c a u s e d b y s m a ll s o lu b le im m u n e
c o m p le x e s fo r m e d b y s o lu b le p ro te in a n tig e n s b in d in g to th e Ig G m a d e a g a in s t
th e m . S o m e o f th e s e im m u n e c o m p le x e s b e c o m e d e p o s ite d in th e w a lls o f s m a ll
b lo o d v e s s e ls o r th e a lv e o li o f th e lu n g s . T h e im m u n e c o m p le x e s a c tiv a te
c o m p le m e n t a n d in itia te a n in fla m m a to r y r e s p o n s e th a t d a m a g e s th e tis s u e .
• T y p e IV h y p e r s e n s itiv ity r e a c tio n s a re c a u s e d b y th e p r o d u c ts o f a n tig e n -s p e c ific
e ffe c to r T c e lls . M o s t r e a c tio n s a re c a u s e d b y C D 4 T H1 c e lls .
im m u n o lo g y 195

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith

h u m o r a l im m u n it y .

• p r o v id e s im m u n ity a g a in s t e x tr a c e llu la r p a th o g e n s
• p r o v id e s im m u n ity a g a in s t in tr a c e llu la r p a th o g e n s
• m e d ia t e d b y T - c e lls
• m e d ia te d b y a n tib o d ie s p r o d u c e d b y B - c e lls
• a n tib o d ie s n e u tr a liz e a n d e lim in a te p a th o g e n s a n d to x in s

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • p r o v id e s im m u n ity a g a in s t e x tr a c e llu la r p a th o g e n s
• m e d ia te d b y a n tib o d ie s p r o d u c e d b y B -c e lls
• a n tib o d ie s n e u tr a liz e a n d e lim in a te p a th o g e n s a n d to x in s
T h e a d a p tiv e im m u n e s y s t e m e v o lv e d in v e r te b r a te s a s a r e s p o n s e to
p a th o g e n s th a t e v o lv e d r e s is ta n c e to th e in n a te im m u n e r e s p o n s e . In it ia tio n o f
th e a d a p tiv e im m u n e r e s p o n s e r e lie s o n th e a c tiv it ie s o f th e in n a te im m u n e
s y s te m .
C h a r a c te r is tic s o f th e a d a p tiv e im m u n e r e s p o n s e :
• It h a s b o th c e llu la r a n d h u m o r a l c o m p o n e n ts
• It is a c tiv a te d b y th e a c tio n s o f th e in n a te im m u n e s y s te m
• It s u p p le m e n ts th e p r o te c t io n p r o v id e d b y in n a t e im m u n it y
• It h a s a s lo w r e s p o n s e b e c a u s e a n t ig e n e x p o s u r e d o e s n 't r e s u lt in im m e d ia te
d e fe n s e
• It is a t a ilo r - m a d e r e s p o n s e th a t is h ig h ly s p e c if ic to th e in v a d in g p a th o g e n :
it is a b le to r e c o g n iz e a s p e c ific p a th o g e n
• It le a d s to th e d e v e lo p m e n t o f im m u n o lo g ic a l m e m o r y ( a n a m n e s tic
r e s p o n s e ) : r e - e x p o s u r e to th e s a m e a n t ig e n w ill r e s u lt in a fa s te r , m o r e
in te n s e r e s p o n s e
T h e r e a r e tw o ty p e s o f a d a p tiv e im m u n ity :
1. H u m o r a l im m u n ity :
• D e s ig n e d to p r o v id e im m u n ity a g a in s t e x tr a c e llu la r p a th o g e n s
• M e d ia te d b y a n tib o d ie s p r o d u c e d b y B - c e lls
• A n tib o d ie s n e u tr a liz e a n d e lim in a t e p a t h o g e n s a n d to x in s fr o m th e b lo o d ,
fr o m m u c o s a l s u r f a c e s a n d fr o m th e lu m e n o f m u c o s a l o r g a n s
2 . C e ll-m e d ia te d im m u n ity :
• D e s ig n e d to p r o v id e im m u n it y a g a in s t in t r a c e llu la r p a t h o g e n s
• M e d ia t e d b y T - c e lls w h ic h a c tiv a te m a c r o p h a g e s to k ill p h a g o c y to s e d
m ic r o b e s (T h e lp e r c e lls ) a n d k ill in fe c te d c e lls , h e n c e e lim in a tin g r e s e r v o ir s
o f in fe c tio n ( c y to to x ic T c e lls )
im m u n o lo g y 196

A ll o f th e fo llo w in g s ta te m e n ts re g a r d in g th e m a jo r h is to c o m p a tib ility

c o m p le x (M H C ) m o le c u le a r e tr u e E X C E P T o n e . W h ic h o n e is th e
E X C E P T IO N ?

• it p la y s a r o le in th e a c u te r e je c tio n o f t r a n s p la n te d tis s u e
• it a s s is ts T - c e lls in th e r e c o g n it io n o f in tr a c e llu la r p a th o g e n s
• it is a g ly c o p r o te in s e c r e te d b y a c tiv a te d p la s m a c e lls
• it is a b le to in te r a c t w ith th e T - c e ll r e c e p to r
• it is c o d e d b y a g r o u p o f h ig h ly p o ly m o r p h ic g e n e s

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • it is a g ly c o p ro te in s e c re te d b y a c tiv a te d p la s m a cells
*** M H C m o le c u le s a re m e m b ra n e g ly c o p r o te in s th a t a re n o t s e c re te d b y a n y c e ll
ty p e .
T h e m a jo r h is to c o m p a tib ility c o m p le x (M H C ) g e n e s a re a h ig h ly p o ly m o r p h ic g ro u p of
g e n e s ; th a t is to s a y th a t m a n y d iffe r e n t v a r ia n ts (a lle le s ) e x is t s im u lta n e o u s ly in a
p o p u la tio n . In h u m a n s , th e M H C g e n e s a re lo c a te d o n th e s h o rt a rm o f c h ro m o s o m e
six. T h e y a re d iv id e d in to th re e s u b g ro u p s : M H C c la s s I, M H C c la s s II, a n d M H C c la s s
III. C la s s e s I a n d II c o d e fo r m e m b ra n e g ly c o p r o te in s (s e e b e lo w ) w h ile c la s s III c o d e s
fo r p ro te in s o f th e c o m p le m e n t s y s te m (C 2 , C 4 , a n d fa c to r B).
T h e m a jo r h is to c o m p a tib ility c o m p le x (M H C ) m o le cu le is a h e te r o d im e ric
m e m b ra n e g ly c o p r o te in e n c o d e d b y th e m ajor h is to co m p a tib ility c o m p lex g e n e s .
T h e ir p rim a ry fu n c tio n is to p re s e n t (d is p la y ) a n tig e n ic p e p tid e s fo r re c o g n itio n b y T -
ly m p h o c y te s . U p o n in te ra c tio n w ith a n M H C /p e p tid e c o m p le x , th e T - c e ll c a n “ d e c id e ”
w h e th e r th e p e p tid e is s e lf o r fo re ig n , a n d ta k e a p p r o p r ia te a c tio n .
T h e re a re tw o s tr u c tu r a lly d is tin c t ty p e s o f M H C m o le c u le s :
1. M H C c la s s I
• E n c o d e d b y M H C c la s s I g e n e s
• C o m p o s e d o f o n e a lp h a c h a in a n d o n e b e ta 2 - m ic r o g lo b u lin c h a in
• E x p re s s e d b y all n u c le a te d c e lls
• R e c o g n iz e d b y C D 8 + T -c e lls
• B in d s a n d p re s e n ts p e p tid e s d e rive d fro m c y to s o lic p ro tein s
2. M H C c la s s II
• E n c o d e d b y M H C c la s s II g e n e s
• C o m p o s e d o f o n e a lp h a a n d o n e b e ta c h a in
• E x p re s s e d o n ly b y p ro fe s s io n a l a n tig e n p re s e n tin g c e lls (A P C ), m a c r o p h a g e s a nd
B -c e lls
• R e c o g n iz e d b y C D 4 + T -c e lls
• B in d s a n d p re s e n ts p e p tid e s d e riv e d fro m e n d o c y to s e d p ro te in s
N ote: In h u m a n s , th e M H C m o le c u le s a re re fe rre d to a s H u m an L e u k o c y te A n tig e n s
(H L A ). H L A tis s u e ty p in g is u s e d to m a tc h d o n a te d tis s u e /o r g a n s /b o n e m a rro w w ith
tr a n s p la n t re c ip ie n ts . A m is m a tc h re s u lts in a c u te re je c tio n o f th e tra n s p la n te d tis s u e .
v a c c in e s 197

A lth o u g h m a n y s u b s ta n c e s a n d p r e p a r a tio n s a r e k n o w n to be
a d ju v a n ts , th e o n ly a d ju v a n ts a p p r o v e d fo r u s e in h u m a n v a c c in e s
are:

• F r e u n d 's c o m p le te a d ju v a n t a n d A lu m
• F r e u n d 's in c o m p le te a d ju v a n t a n d M F 5 9
• I m m u n e s tim u la to r y c o m p le x e s ( IS C O M s ) a n d A lu m
• A lu m a n d M F 5 9

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • A lu m a n d M F 59
A p re r e q u is ite fo r a g o o d im m u n e re s p o n s e is a s ta te of in fla m m a tio n . D u rin g an
in fe c tio n th is is in itia te d b y m ic ro b ia l p r o d u c ts th a t a c tiv a te th e in n a te im m u n e
re s p o n s e . T o w o r k e ffe c tiv e ly , v a c c in a tio n m u s t a ls o c re a te a s ta te o f in fla m m a tio n at
th e s ite in th e b o d y w h e r e th e a n tig e n s a re in je c te d . In g e n e ra l, im m u n iz a tio n w ith
p u rifie d p ro te in a n tig e n s le a d s to a fe e b le im m u n e r e s p o n s e . A re s p o n s e to s u c h
a n tig e n s c a n b e e n h a n c e d b y s u b s ta n c e s th a t in d u c e in fla m m a tio n b y a n tig e n -
in d e p e n d e n t m e c h a n is m s . S u c h e n h a n c in g s u b s ta n c e s a re c a lle d a d ju v a n ts . In
e x p e rim e n ta l im m u n o lo g y th e m o s t e ffe c tiv e a d ju v a n t is F re u n d 's c o m p le te
a d ju v a n t.

A d ju v a n t n a m e C o m p o s i ti o n M e c h a n is m o f a c ti o n

F r e u n d 's in c o m p le te a d ju v a n t O il - in - w a te r e m u l s i o n D e l a y e d r e le a s e o f a n ti g e n : e n h a n c e d u p ta k e b y m a c r o p h a g e s

F r e u n d 's c o m p le t e e m u ls io n O il - in - w a te r e m u ls io n w ith D e l a y e d re le a s e o f a n ti g e n ; e n h a n c e d u p ta k e b y
d e a d m y c o b a c te r ia m a c r o p h a g e s : in d u c ti o n o f c o - s t im u la to r s in m a c r o p h a g e s

F r e u n d 's a d ju v a n t w it h M D P O il - in - w a te r e m u ls io n w ith S i m il a r to F r e u n d 's c o m p le t e a d ju v a n t

m u r a m y l d ip e p ti d e (M D P ) ,
o c o n s t it u e n t o f m y c o b a c te r ia

A lu m (a lu m in u m h y d r o x id e ) A lu m in u m h y d r o x id e g e l D e l u y c d r e le a s e o f a n ti g e n : e n h a n c e d m a c r o p h a g e u p ta k e

A lu m p lu s A lu m in u m h y d r o x id e g e l D e l a y e d r e le a s e o f a n ti g e n ; e n lia n c c d u p ta k e b y
D o rd e te lla p e rt u s s i s w ith k il l e d 11. p e rt u s s i s m a c r o p h a g e s : in d u c ti o n o f c o -s t im u la to r s

Im m u n e s t im u la to ry M a tr ix o f lip id m ic e l le s D e l iv e r s a n ti g e n t o c y to s o l: a ll o w s in d u c tio n o f c y to to x ic T
c o m p le x e s ( IS C O M s ) c o m u in in g v i r a l p r o te i n s c e lls

M F59 S q u n l e n e -o i l- w a te r e m u l s i o n D e l a y e d r e le a s e o f a n tig e n

A lth o u g h m a n y s u b s ta n c e s a n d p r e p a r a tio n s a re k n o w n to b e a d ju v a n ts , th e o n ly
a d ju v a n ts a p p ro v e d fo r u s e in h u m a n v a c c in e s a re alu m - a fo rm o f a lu m in u m
h y d ro x id e - a n d a n e m u ls io n o f s q u a le n e , o il, a n d w a te r c a lle d M F 59. B e c a u s e
v a c c in e s a re g iv e n to la rg e n u m b e rs o f h e a lth y p e o p le , th e s a fe ty s ta n d a rd s fo r
v a c c in e s a re h ig h a n d d o n o t to le ra te th e s id e e ffe c ts o f th e m o s t p o te n t a d ju v a n ts .
Im p o rtan t point: T h e u se o f a d ju v a n ts e lim in a te s th e n e e d fo r r e p e a te d b o o s te r
d o s e s o f th e a n tig e n a n d p e rm its th e u s e o f s m a lle r d o s e s o f th e a n tig e n in th e
v a c c in e .
v a c c in e s 198

A b a c te r ia l to x in t h a t h a s b e e n w e a k e n e d u n til it is n o lo n g e r to x ic b u t
is s tro n g e n o u g h to in d u c e th e fo r m a tio n o f a n tib o d ie s a n d im m u n ity
to th e s p e c if ic d is e a s e c a u s e d b y th e to x in is c a lle d a (a n ):

• a n t ito x in
• a n tiv e n in
• a n tis e r u m
• to x o id

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • to x o id
A to x o id is a b a c te r ia l to x in w h o s e to x ic it y h a s b e e n w e a k e n e d o r d e s tr o y e d
b y e it h e r c h e m ic a l ( fo r m a ld e h y d e ) o r h e a t t r e a t m e n t . A lt h o u g h t h e y h a v e lo s t
t h e ir t o x ic p r o p e r tie s , t o x o id s s till r e ta in t h e ir im m u n o g e n ic ity ; th e r e fo r e , t h e y
a r e a b le to in d u c e th e p r o d u c t io n o f s p e c if ic a n tito x in a n tib o d ie s . T o x o id
v a c c in e s a r e u s u a lly a d m in is t e r e d w it h a n a d ju v a n t a n d a r e u s e fu l a g a in s t
d ip h t h e r ia , te t a n u s , p e r t u s s is a n d o t h e r d is e a s e s .
A n tito x in is a n a n t ib o d y f o r m e d in re s p o n s e to a s p e c if ic to x in . A s e ru m
c o n t a in in g a n tito x in s c a n b e u s e d f o r e it h e r th e t r e a t m e n t o r p r e v e n t io n o f
c e r ta in b a c te r ia l d is e a s e s . T h e a n t it o x in c a n n e u t r a liz e a n u n b o u n d to x in to
p r e v e n t th e d is e a s e f r o m p r o g r e s s in g . T e ta n u s a n tito x in is u s e d b o th in th e
t r e a t m e n t o f te t a n u s a n d in its p r e v e n t io n ( p r o p h y la x is ) . B o tu lin u m a n tito x in
is used in t h e t r e a t m e n t o f b o tu lis m . D ip h th e r ia a n tito x in is u s e d in th e
t r e a t m e n t o f d ip h th e r ia .
_ 1 . A s w ith o t h e r in a c tiv a te d v a c c in e s , t h e r e a r e d is a d v a n t a g e s w it h
t o x o id v a c c in e s . E v e n w it h a n a d ju v a n t a d d e d , th e s e v a c c in e s d o
n o t p r o d u c e a fu ll im m u n e r e s p o n s e . B o o s t e r s h o t s a r e n e e d e d to
m a in t a in t h e im m u n ity .
2 . Im m u n e g lo b u lin s r e f e r t o a n t ib o d ie s u s e d in p a s s iv e
im m u n iz a t io n .
3 . T o x o id s a r e u s e d to in d u c e a c tiv e im m u n iz a t io n .
4 . A n tis e r u m is th e flu id c o m p o n e n t o f c lo t t e d b lo o d fr o m a n im m u n e
in d iv id u a l t h a t c o n t a in s a n t ib o d ie s a g a in s t a g iv e n a n tig e n .
A n t is e r u m c o n t a in s a h e t e r o g e n o u s c o lle c tio n o f a n t ib o d ie s t h a t
b in d to a n tig e n .
5 . A n tiv e n in is a m a te r ia l u s e d to n e u t r a liz e th e v e n o m o f a
p o is o n o u s a n im a l. P r e p a r e d b y im m u n iz a t io n o f s e r u m - p r o d u c in g
a n im a ls , u s u a lly h o r s e s .
v a c c in e s 199

H u m a n H B IG to p r e v e n t h e p a tit is B in th o s e n o t a c tiv e ly im m u n iz e d
w ith th e H e p B v a c c in e is a n e x a m p le o f:

• n a tu r a lly a c q u ir e d p a s s iv e im m u n it y
• n a tu r a lly a c q u ir e d a c tiv e im m u n it y
• a r tific ia lly a c q u ir e d a c tiv e im m u n ity
• a r tific ia lly a c q u ir e d p a s s iv e im m u n it y

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a r tific ia lly a c q u ir e d p a s s iv e im m u n ity
R e m e m b e r : A c q u ir e d ( p r o te c tiv e ) im m u n ity o c c u r s n a tu r a lly a n d a r tific ia lly .
It c a n b e a c tiv e o r p a s s iv e .
1. N a tu r a lly :
• A c tiv e : p e r s o n is e x p o s e d to a n a n tig e n a n d th e b o d y p r o d u c e s
a n tib o d ie s . F o r e x a m p le , r e c o v e r y fr o m a n in f e c t io n w ith m u m p s v ir u s
c o n fe r s life lo n g im m u n ity .
• P a s s iv e : a n tib o d ie s ( Ig G ) p a s s e d fro m m o th e r to fe tu s d u r in g p r e g n a n c y
a n d Ig A p a s s e d fr o m m o th e r to n e w b o r n d u r in g b r e a s t- fe e d in g

2 . A r tific ia lly :
• A c tiv e : v a c c in a tio n w ith k ille d , in a c tiv a te d , o r a tte n u a te d b a c te r ia o r to x o id
• P a s s iv e : in je c tio n o f im m u n e s e r u m o r g a m m a - g lo b u lin
R e m e m b e r : S o m e o f th e ly m p h o c y te s s e le c te d d u r in g a n a d a p tiv e im m u n e
r e s p o n s e p e r s is t in th e b o d y a n d p r o v id e lo n g - t e r m im m u n o lo g ic a l m e m o r y o f
th e p a th o g e n . T h e a d a p tiv e im m u n ity p r o v id e d b y im m u n o lo g ic a l m e m o r y is a ls o
c a lle d a c q u ir e d im m u n ity o r p r o te c tiv e im m u n ity . F o r s o m e p a th o g e n s s u c h
a s m e a s le s v ir u s , o n e fu ll- b lo w n in f e c t io n c a n p r o v id e im m u n it y fo r d e c a d e s ,
w h e r e a s fo r in f lu e n z a e th e e f fe c t s e e m s m o r e s h o r t - liv e d . T h is is n o t b e c a u s e
th e im m u n o lo g ic a l m e m o r y is f a u lty b u t b e c a u s e th e in flu e n z a v ir u s c h a n g e s o n
a y e a r ly b a s is t o e s c a p e th e im m u n ity a c q u ir e d b y its h u m a n h o s ts . A v ir u s
c h a n g e s its h e m a g g lu tin in ( H A ) a n d n e u r a m in id a s e ( N A ) p r o te in s . A c q u ir e d o r
a d a p tiv e im m u n it y is s to r e d in m e m o r y B a n d T c e lls .
Im p o r ta n t: T h e p u r p o s e o f th e r a b ie s v a c c in e a n d te ta n u s v a c c in e ( e x a m p le s o f
a r tific ia lly a c q u ir e d a c t iv e im m u n it y ) is to e lic it a n im m u n e r e s p o n s e b e fo r e th e
o n s e t o f d is e a s e s y m p to m a to lo g y . T h e e ffe c tiv e n e s s o f th is ty p e o f v a c c in e
d e p e n d s o n th e r e la tiv e ly s lo w d e v e lo p m e n t o f th e in f e c t in g p a th o g e n p r io r to
th e o n s e t o f d is e a s e s y m p to m s a n d th e a b ility o f th e v a c c in e to in itia t e
a n tib o d y p r o d u c tio n b e fo re th e a c tiv e to x in s a r e p r o d u c e d a n d r e le a s e d to th e
s ite w h e r e th e y c a n c a u s e s e r io u s d is e a s e s y m p to m s .
v a c c in e s 200

A il o f th e fo llo w in g v a c c in e s c o n ta in a tte n u a te d v ir u s E X C E P T o n e .
W h ic h o n e is th e E X C E P T IO N ?

• y e llo w fe v e r
• m e a s le s
• in flu e n z a
• m um ps

• r u b e lla

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • in flu e n z a
V ir a l v a c c in e s c a n c o n ta in e it h e r a n a tte n u a te d liv e v ir u s ( o n e t h a t e x h ib its
d e c r e a s e d v ir u le n c e ) ; a n in a c tiv a te d v ir u s t h a t is n o lo n g e r c a p a b le o f
p r o d u c in g d is e a s e b u t s till r e ta in s t h e im m u n o g e n ic it y o f th e liv e v ir u s ; o r
p a r ts o f th e w h o le v ir u s ( p u r ifie d o r s y n th e tic ) . V a c c in e s c o n t a in in g a t t e n u a t e d
liv e v ir u s a r e m o r e e f f e c t iv e b e c a u s e th e y e lic it a ll t h e in n a te a n d a d a p tiv e
im m u n e r e s p o n s e s t h a t t h e liv e v ir u s w o u ld .
A v a i l a b l e v a c c i n e s f o r i n f e c t i o u s d i s e a s e s in h u m a

B a c te ria l diseas es T y p e o f V a cc in e V ira l diseas es T y p e s o f v ac c in e

D ip h th e ri a T o x o id Y e llo w fe v e r A tte n u a te d v ir u s

T e ta n u s T o x o id M e a s le s A tte n u a te d v ir u s

P e rt u s s is K ill e d b a c te ri a , s u b u n it v a c c in e M um ps A tte n u a te d v iru s

c o m p o s e d o f p e r tu s s i s to x o id a n d
o th e r b a c te ri a l a n d g e n s

P araty p h o id fev er K ill e d b a c te ria R u b e lla A tte n u a te d v iru s

( S a lm o n e lla p a ra ty p h i)

T y p h u s fe v e r K ill e d b a c te ria P o lio A tte n u a te d v i r u s (S a b in ) o r k il le d v iru s

( R ic k e tts ia p r o w a z e k ii) (S a lk )

C h o le ra ( V ib ri o c h o le ra ) K ille d b a c te ri a o r c e ll e x t ra c t V a r ic e l la (c h ic k e n p o x ) A tte n u a te d v iru s

P la g u e ( Y e r s i n ia p c s ti s ) K ille d b a c te ri a o r c e ll e x t ra c t In flu e n z a I n a c t iv a te d v iru s

T u b e rc u lo s is A tte n u a t e d s tr a i n o f b o v in e R a b ie s I n a c t iv a te d v iru s
M y c o b a c t e r iu m tu b e rc u lo s i s (B C G )

T y p h o i d f e v e r ( S a lm o n e lla V i p o l y s a c c h a ri d e s u b u n it v a c c in e s H e p a t iti s A S u b u n it v a c c in e ( r e c o m b in a n t h e p a t iti s

ly p h i) l. iv c - a ltc n u a te d o r a l v a c c in e a n tig e n )

M e n i n g iti s (N e is s e ri a P u ri fi e d c a p s u la r p o ly s a c c h a ri d e H e p a t iti s B S u b u n it v a c c in e (re c o m b in a n t h e p a t iti s

m e n i n g iti d is ) a n tig e n )

B a c t e r ia l p n e u m o n ia P u ri fi e d c a p s u la r p o ly s a c c h a ri d e H u m a n p a p ill o m a v i ru s j S u b u n it v a c c in e ( v ir u s c o a t p ro te in s )
( S t re p t o c o c c u s p n e u m o n ia e )

M e n i n g iti s (H a e m o p h ilu s H . in fl u e n z a e p o ly s a c c h a ri d e R o t a v ir u s A tte n u a te d v iru s

in flu e n z a e c o n j u g a te d t o p ro te in R e c o m b in a n t liv e v iru s
v a c c in e s 201

E a c h o f th e fo llo w in g a r e a n e x a m p le o f a liv e a tte n u a te d b a c te ria l

v a c c in e E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• m y c o b a c te r iu m b o v is v a c c in e
• s a lm o n e lla ty p h i v a c c in e
• y e r s in ia p e s tis v a c c in e
• c o x ie lla b u r n e tti v a c c in e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a ri I - V o l u m e 13 * © 2 0 1 7
 • y e r s in ia p e s tis v a c c in e
C a p s u la r p o ly s a c c h a r id e v a c c in e s ( th e s e v a c c in e s c o n ta in p o ly s a c c h a r id e
c a p s u la r m a te r ia l fr o m th e b a c te r ia , u s u a lly c o n ju g a t e d to p r o te in fo r
g r e a t e r im m u n o g e n ic it y ) :
• S t r e p t o c o c c u s p n e u m o n ia v a c c in e ( fo r p n e u m o n ia )
• N e is s e r ia m e n in g it id e s v a c c in e ( fo r m e n in g itis )
• H a e m o p h ilu s in flu e n z a e v a c c in e ( fo r m e n in g itis )
T o x o i d v a c c in e s :
• C o r y n e b a c t e r iu m d ip h t h e r ia e v a c c in e ( fo r d ip h th e r ia )
• C lo s tr id iu m t e ta n i v a c c in e ( f o r t e ta n y )
K ille d b a c te r ia l v a c c in e s :
• B o r d e te lla p e r tu s s is v a c c in e ( fo r w h o o p in g c o u g h )
• V ib r io c h o le r a e v a c c in e ( fo r c h o le r a )
• R ic k e tt s ia p r o w a z e k ii v a c c in e ( f o r ty p h u s fe v e r )
• Y e r s in ia p e s tis v a c c in e ( fo r p la g u e )
L iv e a tte n u a te d b a c te r ia l v a c c in e s :
• M y c o b a c te r iu m b o v is v a c c in e ( f o r T B )
• S a lm o n e lla ty p h i v a c c in e ( fo r ty p h o id fe v e r )
• F r a n c is e lla tu la r e n s is v a c c in e ( fo r tu la r e m ia )
• C o x ie lla b u r n e tti v a c c in e ( fo r Q fe v e r )
* * * A c tiv e im m u n ity is in d u c e d b y v a c c in e s p r e p a r e d fr o m b a c te r ia o r t h e ir
p r o d u c ts . P a s s iv e im m u n ity is p r o v id e d b y th e a d m in is t r a t io n o f p r e fo r m e d
a n t ib o d ie s in p r e p a r a t io n s c a lle d im m u n e g lo b u lin s . P a s s iv e -a c tiv e
im m u n it y in v o lv e s g iv in g b o th im m u n e g lo b u lin s t o p r o v id e im m e d ia te
p r o te c tio n a n d a v a c c in e t o p r o v id e lo n g te r m p r o te c tio n .
v a c c in e s 202

P e r s o n s v a c c in a te d a g a in s t h e p a titis B vii w h o h a v e d e v e lo p e d
im m u n ity a r e a ls o im m u n e to th e :

• h e p a titis A v ir u s
• h e p a titis C v ir u s
• h e p a titis D v ir u s
• h e p a titis E v ir u s

M IC R O B IO L O G Y /P A T H O L O G Y (IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • h e p a titis D v ir u s
H e p a titis D v ir u s ( H D V ) is a n R N A v ir u s , w h ic h is in c a p a b le o f c o m p le t in g its
o w n r e p lic a tio n w ith in in fe c te d h o s t c e lls . It r e q u ir e s a n d u s e s e x c e s s h e p a titis
B s u r f a c e a n tig e n ( H B s A g ) m o le c u le s fr o m a n e x is tin g o r c o n c u r r e n t h e p a titis
B v ir u s ( H B V ) in fe c tio n a s its m a jo r c a p s id p r o te in . A s a r e s u lt, H D V h a s b e e n
s o m e t im e s r e fe r r e d t o “ p a r a s it e ” o f H B V . W h e n a p e r s o n is im m u n e a g a in s t
h e p a t it is B , H B V r e p lic a t io n d o e s n o t o c c u r a n d H B s A g is u n d e t e c t a b le . T h a t
p r o te c tio n is b e lie v e d to e x te n d to p r e v e n t H D V in fe c tio n .
R e m e m b e r : It h a s b e e n w e ll e s t a b lis h e d t h a t H B V is t h e m o s t in fe c tio u s
know n b lo o d b o r n e p a th o g e n . T h e d e v e lo p m e n t a n d im p le m e n t a t io n o f
u n iv e r s a l, and now s ta n d a r d , in fe c tio n c o n tr o l r e c o m m e n d a t io n s and
r e g u la t io n s c o n t in u e d to u s e th is DNA v ir u s a s t h e ir p r im a r y o c c u p a t io n a l
b lo o d b o r n e ta r g e t .
d is e a s e s 203

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith

r h e u m a tic fe v e r .

• p a n c a r d itis
• g r o u p B s tr e p to c o c c i
• k o p lik s p o ts
• b u llo u s s k in le s io n s

• a s c h o ff b o d ie s
• s y d e n h a m c h o re a

M IC R O B IO L O G Y /P A T H O L O G Y I^ d e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • pan card itis
• a sc ho ff bodies
• syd en h am chorea
A c u te R F ty p ic a lly a p p e a rs 10 d a y s to 6 w e e k s a fte r a n e p is o d e o f p h a ry n g itis c a u s e d b y
g ro u p A s trep to co cci. In p a r tic u la r, s tr e p p y o g e n e s . It o c c u r s m o s t o fte n in c h ild re n
b e tw e e n a g e s 5 a n d 15, b u t fir s t a tta c k s c a n o c c u r in m id d le to la te r life .
R f is c h a r a c te riz e d b y a c o n s te lla tio n o f fin d in g s th a t in c lu d e s a s m ajor m anifestations:
(1 ) m ig ra to r y p o ly a r th r itis o f th e la rg e jo in ts , (2 ) p a n c a r d itis , (3) s u b c u ta n e o u s n o d u le s , (4)
e ry th e m a m a r g in a tio n o f th e s k in , a n d (5 ) s y d e n h a m c h o re a , a n e u ro lo g ic d is o rd e r w ith
in v o lu n ta r y ra p id , p u r p o s e le s s m o v e m e n ts .
T h e d ia g n o s is is e s ta b lis h e d b y th e s o - c a lle d Jon es criteria: e v id e n c e o f a p re c e d in g
g ro u p A s tr e p to c o c c a l in fe c tio n , w ith th e p re s e n c e o f tw o o f th e m a jo r m a n ife s ta tio n s o r
o n e m a jo r a n d tw o m in o r m a n ife s ta tio n s (n o n s p e c ific s ig n s a n d s y m p to m s th a t in c lu d e
fe v e r, a rth r a lg ia , o r a n e le v a te d tite r o f a n tis tre p to ly s in O [A S O ] w h ic h is e v id e n c e o f a
r e c e n t s tre p to c o c c i in fe c tio n ).
Im portant: D u rin g a c u te R F , fo c a l in fla m m a to r y le s io n s a re fo u n d in v a rio u s tis s u e s .
D is tin c tiv e le s io n s o c c u r in th e h e a rt, c a lle d A sc h o ff bodies, w h ic h c o n s is t o f fo c i of
ly m p h o c y te s ( p r im a rily T c e lls ) , o c c a s io n a l p la s m a c e lls , a n d p lu m p a c tiv a te d
m a c r o p h a g e s c a lle d A n its ch k ow c ells ( p a th o g n o m o n ic fo r R F ).
Rem em ber: D u rin g a c u te R F , d iffu s e in fla m m a tio n a n d A s c h o ff b o d ie s m a y b e fo u n d in
a n y o f th e th re e la y e rs o f th e h e a rt, c a u s in g pericarditis, m yo card itis, o r end o card itis
( p a n c a rd itis ).
A fte r a n in itia l a tta c k th e r e is in c re a s e d v u ln e r a b ility to r e a c tiv a tio n o f th e d is e a s e w ith
s u b s e q u e n t p h a ry n g e a l in fe c tio n s , a n d th e s a m e m a n ife s ta tio n s a re lik e ly to a p p e a r w ith
e a c h r e c u r re n t a tta c k . D am ag e to the valves is cum ulative. C lin ic a l m a n ife s ta tio n s
a p p e a r y e a r s o r e v e n d e c a d e s a fte r th e in itia l e p is o d e o f R F a n d d e p e n d o n w h ic h c a rd ia c
v a lv e s a re in v o lv e d . In a d d itio n to v a rio u s c a rd ia c m u r m u r s , c a rd ia c h y p e rtro p h y a n d
d ila tio n , a n d h e a rt fa ilu re , in d iv id u a ls w ith ch ron ic R H D (R h e u m a tic H e a rt D is e a s e ) m a y
h a v e a rr h y th m ia s , th r o m b o e m b o lic c o m p lic a tio n s , a n d in fe c tiv e e n d o c a rd itis .
T h e c a r d in a l a n a to m ic c h a n g e s o f th e m itral valve in c h r o n ic R H D a re le a fle t th ic k e n in g ,
c o m m is s u r a l fu s io n a n d s h o r te n in g , a n d th ic k e n in g a n d fu s io n o f th e te n d in o u s c o rd s .
d is e a s e s 204

A ll o f th e fo llo w in g a re c h a r a c te r is tic s o f A d d is o n 's d is e a s e E X C E P T

o n e . W h ic h o n e is th e E X C E P T IO N ?

• h y p e r te n s io n
• in c r e a s e d p ig m e n ta tio n o f th e s k in
• h y p o g ly c e m ia
• in c r e a s e d s e r u m p o ta s s iu m

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 h y p e rten sio n
* * * T h is is fa ls e ; A d d is o n 's d is e a s e is c h a r a c te r iz e d b y h y p o te n s io n .
A d d is o n 's d is e a s e ( p r im a r y a d r e n o c o r tic a l d e fic ie n c y ) is a life th re a te n in g c o n d itio n
c au se d by p a rtial or c o m p le te fa ilu re of a d r e n o c o rtic a l fu n c tio n . It is m o s t
c o m m o n ly d u e to id io p a th ic a d re n a l a tro p h y ( a u to im m u n e ly m p h o c y tic a d r e n a litis ) .
It c a n a ls o b e c a u s e d b y tu b e r c u lo s is ( fo r m e r ly m o s t c o m m o n c a u s e ) , m e ta s ta tic
tu m o r , a n d v a r io u s in fe c tio n s . It is c h a ra c te r iz e d b y th e in s id io u s o n s e t o f w e a k n e s s ,
fa tig u e , d e p r e s s io n , h y p o te n s io n a n d b r o n z in g o f th e e n tire s k in . O ra l s ig n s c o n s is t
o f d iffu s e p ig m e n ta tio n o f th e g in g iv a , to n g u e , h a r d p a la te , a n d b u c c a l m u c o s a .
A lth o u g h c u ta n e o u s p ig m e n ta tio n w ill m o s t lik e ly d is a p p e a r fo llo w in g th e r a p y ,
p ig m e n ta tio n o f th e o r a l tis s u e s te n d s to p e rs is t.
T h e a d re n o c o rtic o tro p ic h o rm o n e te s t ( a ls o k n o w n a s a n A C T H te s t o r a
c o r tic o tr o p in te s t) m e a s u r e s p itu ita r y g la n d fu n c tio n . T h e p itu ita r y g la n d p r o d u c e s th e
h o r m o n e A C T H , w h ic h s tim u la te s th e o u te r la y e r o f th e a d r e n a l g la n d (th e a d r e n a l
c o r te x ) . M o r e s p e c ific a lly , it s tim u la te s s e c r e tio n o f g lu c o c o rtic o id s s u c h a s c o r tis o l,
a n d h a s little c o n tr o l o v e r th e s e c r e tio n o f a ld o s te r o n e , th e o th e r m a jo r s te r o id
h o r m o n e fro m th e a d r e n a l c o r te x . T h e A C T H te s t is u s e d to d e te r m in e if to o m u c h
c o r tis o l is b e in g p r o d u c e d ( C u s h in g 's s y n d r o m e ) o r if n o t e n o u g h c o r tis o l is b e in g
p r o d u c e d ( A d d is o n 's d is e a s e ) .
1. S e c o n d a ry a d ren al in s u ffic ie n c y c a n r e s u lt fr o m p r o lo n g e d o r
im p ro p e r u s e o f g lu c o c o r tic o id h o r m o n e s , w h ic h a r e u s e d to tre a t
r h e u m a to id a r th r itis , a s th m a , a n d o th e r in fla m m a to r y illn e s s e s .
2. A d d is o n 's d is e a s e is tr e a te d b y a d m in is te rin g c o rtiso l ( h y d r o c o r tis o n e ) .
3. W a te rh o u s e -F rid e ric h s e n s y n d ro m e is a c a ta s tr o p h ic a d r e n a l
in s u ffic ie n c y a n d v a s c u la r c o lla p s e d u e to h e m o r r h a g ic n e c r o s is o f th e
a d r e n a l c o r te x . It is c h a r a c te r is tic a lly d u e to m e n in g o c o c c e m ia , m o s t
o fte n in a s s o c ia tio n w ith m e n in g o c o c c a l m e n in g itis .
4. T h e a d ren al g la n d s a r e lo c a te d o n to p o f e a c h k id n e y . T h e y c o n s is t o f
th e o u te r p o r tio n ( c a lle d th e c o r te x ) a n d th e in n e r p o r tio n (c a lle d th e
m e d u lla ) . T h e c o r te x p r o d u c e s th r e e ty p e s o f h o r m o n e s : sex h o r m o n e s ,
g lu c o c o rtic o id h o r m o n e s , a n d m in e ra lo c o rtic o id h o r m o n e s .
d is e a s e s 205

O s te o a r th r itis (d e g e n e r a tiv e jo in t d is e a s e ) is th e m o s t c o m m o n ty p e
o f jo in t d is e a s e .
H e b e r d e n n o d e s , b o n y s w e llin g s in th e d is ta l in te r p h a la n g e a l jo in ts ,
a re a c h a r a c te r is tic m o r p h o lo g ic a l c h a n g e .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e fir s t s t a t e m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • b o th s ta te m e n ts a r e tr u e
O s te o a r th r itis ( a k a d e g e n e r a t iv e jo in t d is e a s e ) is th e m o s t c o m m o n t y p e o f
jo in t d is e a s e . It is c h a r a c t e r iz e d b y t h e p r o g r e s s iv e e r o s io n o f a r tic u la r
c a r tila g e . T h e te r m o s t e o a r t h r it is im p lie s a n in f la m m a t o r y d is e a s e ; h o w e v e r ,
e v e n th o u g h in f la m m a t o r y c e lls m a y b e p r e s e n t ( u s u a lly in s m a ll n u m b e r s ) ,
o s t e o a r t h r it is is c o n s id e r e d to b e a n in tr in s ic d is e a s e o f c a r t ila g e in w h ic h
b io c h e m ic a l a n d m e t a b o lic a lt e r a t io n s in in d iv id u a ls w it h g e n e t ic s u s c e p t ib ilit y
r e s u lt in its b r e a k d o w n .
T h e in fla m m a tio n is a c c o m p a n ie d b y p a in , s w e llin g , a n d s t iff n e s s . M o s t
c o m m o n ly it a ff e c t s jo in t s c o n s t a n t ly e x p o s e d t o w e a r a n d te a r . T h e jo in t s
m o s t o fte n a ffe c te d in c lu d e t h e in t e r v e r t e b r a l jo in t s , th e p h a la n g e a l jo in ts ,
th e k n e e s , a n d th e h ip s .
C h a r a c t e r is t ic m o r p h o lo g ic c h a n g e s in c lu d e :
• E x p o s e d s u b c h o n d r a l b o n e p la te b e c o m e s th e n e w a r t ic u la r s u r fa c e , a n d
f r ic tio n w ith th e o p p o s in g d e g e n e r a t e d a r t ic u la r s u r f a c e s m o o t h s a n d
b u r n is h e s t h e e x p o s e d b o n e , g iv in g it th e a p p e a r a n c e o f p o lis h e d iv o r y
(b o n e e b u r n a tio n )
• D u r in g th e s t a g e s o f o s t e o a r t h r it is d is lo d g e d p ie c e s o f c a r t ila g e a n d
s u b c h o n d r a l b o n e t u m b le in to t h e jo in t, f o r m in g lo o s e b o d ie s (jo in t m ic e )
• O s te o p h y te s ( b o n y s p u r s ) c a n f o r m a t t h e d is ta l in t e r p h a la n g e a l jo in t s
(H e b e r d e n n o d e s ) o r a t t h e p r o x im a l in t e r p h a la n g e a l jo in t s (B o u c h a r d
nodes)
T y p e s o f o s te o a r th r itis :
• P r im a r y o s te o a r th r itis : o c c u r s w it h o u t k n o w n c a u s e a n d is m o s t ly r e la te d
t o a g in g
• S e c o n d a r y o s te o a r th r itis : is c a u s e d by a n o t h e r d is e a s e o r c o n d it io n .
C o n d it io n s t h a t c a n le a d to s e c o n d a r y o s t e o a r t h r it is in c lu d e o b e s it y ,
r e p e a te d t r a u m a o r s u r g e r y to th e jo in t s tr u c t u r e s , a b n o r m a l jo in t s a t b ir th
( c o n g e n ita l a b n o r m a lit ie s ) , g o u t , d ia b e t e s a n d o t h e r h o r m o n e d is o r d e r s .
d is e a s e s 206

A ll o f th e fo llo w in g c a n b e c la s s if ie d a s a ty p e o f L a n g e r h a n s c e ll
h is tio c y to s is E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• L e tte r e r - S iw e d is e a s e
• B r u to n d is e a s e
• H a n d - S c h u lle r - C h r is tia n d is e a s e
• e o s in o p h ilic g r a n u lo m a

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • Bruton disease
Histiocytosis X (L a n g e rh a n s cell h is tio c y to s is ) is a te rm u sed to d e s c rib e a g ro u p o f d iffe re n t
ty p e s o f illn e sse s th a t s h a re a c o m m o n o rigin . Langerhans cells (ca lle d h is tio c y te s ) a re
incre a se d in n u m b e r and in va d e v a rio u s tis s u e s o f th e b od y. H istio cyte s a re ce lls n o rm a lly found
th ro u g h o u t th e b od y and a re m ost often fo u n d in the sp le e n , lung, liver, and bone m arrow . The
trig g e r fo r th e incre a se o f L a n g e rh a n s c e lls a nd th e ir in va sio n is n o t know n.
R e g a rd le ss o f th e clin ica l picture, th e p ro life ra tin g L a n g e rh a n s ce lls h ave a b u n d a n t, often
v a cu o la te d c y to p la s m a n d v e s ic u la r n uclei co n ta in in g lin e a r g ro o v e s o r fo lds. T h e p re se n ce of
Birbeck granules in the c yto p la sm , w h ich c o n ta in the p ro te in la n g e rin is ch a ra cte ristic.
L a n g e rh a n s ce ll h is tio c y to s is p re se n ts a s s e ve ra l c lin ic o p a th o lo g ic e n titie s:
• Eosinophilic Granulom a: is c h a ra c te riz e d by p ro life ra tio n s o f L a n g e rh a n s ce lls a d m ixe d
w ith v a ria b le num be rs o f e osin o p h ils, lym p ho cyte s, p la sm a cells, and neu tro p hils. M ost
co m m on and m ost ben ig n form .
• H and-Christian-Schuller Disease: u su a lly re fe rs to c h ild re n w ith th e c la s s ic triad of
ca lva ria l b on e defe cts, d ia b e te s in sip id u s, a nd e xo p h th a lm o s c a u se d by in vo lve m e n t o f the
orbit.
• Letterer-Siw e Disease: o c c u rs m o st fre q u e n tly b e fo re 2 ye a rs o f a ge ; a d o m in a n t clinical
fe a tu re is the d e v e lo p m e n t o f c u ta n e o u s le sio n s re se m b lin g a s e b o rrh e ic e ru p tio n , w h ich is
ca u s e d b y in filtra te s o f L a n g e rh a n s ce lls o v e r th e fro n t and b a ck o f th e tru n k a nd sca lp . T he
c o u rse o f u n tre a te d d is e a s e is ra p id ly fa ta l.
• Pulm onary Langerhans cell histiocytosis: re p re s e n ts a s p e c ia l c a te g o ry o f d ise a se ,
m o st o fte n s e e n in a d u lt s m o ke rs, w h ic h m a y re g re ss s p o n ta n e o u s ly u po n ce ss a tio n of
sm oking.
T h e o u tco m e o f LC H is e x tre m e ly va ria b le . T he tw o m ain fa c to rs w h ic h in flu en ce a child 's
p ro g n o s is a p p e a r to be age a t th e tim e o f d ia g n o sis, and how m any organs a re involved.
C h ildre n y o u n g e r th an 2 y e a rs a t th e tim e o f d ia g n o s is h ave a h ig h e r d e a th rate th a n d o o ld er
ch ild re n. F u rth erm ore, th e p re se n ce o f m a jo r o rg a n p ro b le m s (liver, lung, b on e m arro w ) has been
sh ow n to be an in d ic a to r o f p o o r o u tco m e . T h e inv o lv e m e n t o f m u ltiple o rg a n s y s te m s is a lso a
p o o r p ro g n o s tic sign.
Note: B ruton d ise ase , a lso kn ow n a s X-linked infantile agam m aglobulinem ia fe a tu re s a
d e fe ctive ty ro s in e kina se B ce ll g en e w h ich re su lts in a la ck o f m a tu re B ce lls. T h is d e c re a s e s all
5 im m u n o g lo b u lin isotype s a nd lea ves th e person e xtre m e ly v u ln e ra b le to a w id e a rra y of
in fe ctio n s.
d is e a s e s 207

P r im a r y h y p e r p a r a th y r o id is m is m o s t o fte n c a u s e d by:

• liv e r d is e a s e
• p a r a th y r o id a d e n o m a
• b r o n c h o g e n ic s q u a m o u s c e ll c a r c in o m a
• h y p o c a lc e m ia o f c h r o n ic r e n a l d is e a s e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • parathyroid adenoma
P rim a ry h y p e rp a ra th y ro id is m is one o f th e m o st c o m m o n e n d o c rin e d iso rd e rs, a n d is an
im p o rta n t c a u s e o f hypercalcem ia. It is u su a lly a d is e a s e o f a d u lts a n d is m o re c o m m o n in
w o m e n th a n in m en . M o st c a s e s o c c u r in th e 50s o r la te r in life. T h e m o s t c o m m o n c a u s e of
p rim a ry h y p e rp a ra th y ro id is m is a solitary parathyroid adenoma.
T h e sig n s a n d s y m p to m s o f h y p e rp a ra th y ro id is m re fle ct the co m b in e d e ffe c ts o f in c re a s e d PTH
se cre tio n a n d h yp e rca lce m ia . P rim a ry h y p e rp a ra th y ro id is m is a s s o c ia te d w ith “p a in fu l bones,
renal sto ne s, a b d o m in a l g ro an s, and p sych ic m o a n s /’
The constellation of sym ptom s includes:
• Bone disease a nd b on e pain s e c o n d a ry to fra c tu re s o f b o n e s w e a k e n e d b y o s te o p o ro s is o r
o s te itis fib ro s a c y s tic a
• N ep h ro lithiasis (renal stones)
• G astrointestinal disturbances, in clu ding co n stip a tio n , n au sea , p ep tic ulce rs, pan cre atitis,
and g allston es
• CNS alterations, in clu ding d ep re ssion , lethargy, and e ve n tu a lly se izu re s
• N eurom uscular abnorm alities, in clu ding w e a kne ss a nd fatigue
***Dental finding: T h e re is a loss of lam ina dura around m ultiple teeth.
L ab o ra to ry fin d in g s include: hypercalcem ia, decreased se ru m p ho sp h o ru s, a nd increased
s e ru m PTH.
H y p e rp a ra th y ro id is m o ccu rs in tw o m a jo r fo rm s:
• Primary h y p e rp a ra th y ro id is m is the re su lt o f an a d e n o m a (85 % to 9 5% ), p rim a ry h yp e rp la sia
(5% to 1 0% ), o r c a rc in o m a (<1% )
• Secondary h yp e rp a ra th y ro id is m is ca u s e d by a n y co n d itio n th a t g iv e s rise to c h ro n ic
h yp o ca lce m ia ,w h ich in tu rn leads to c o m p e n s a to ry o v e ra c tiv ity o f th e p a ra th yro id g la n d s. The
clinical fe a tu re s a re u su a lly d o m in a te d b y sym p to m s o f c h ro n ic renal failu re .
Note: In a m in o rity o f p atie nts, p a ra th yro id a ctivity m ay b eco m e a u to n o m o u s a nd e xce ssive , w ith
re su lta n t h yp e rc a lc e m ia , a p ro c e s s th a t is s o m e tim e s te rm e d tertiary hyperparathroidism .
1. In rare instances, h yp o p a ra th yro id ism is a sso cia te d w ith c o n g e n ita l th ym ic
h y p o p la s ia (D iG e o rg e 's syn d ro m e ).
2. Remember: O ste o p o ro sis, ce n tra l g ia n t ce ll g ra n u lo m a s, a n d m e ta sta tic
c a lc ific a tio n s a re all m a n ife s ta tio n s o f hyperparathyroidism .
d is e a s e s 208

F o r e a c h n u m b e r e d s y m p to m lis te d b e lo w , s e le c t th e m o s t c lo s e ly
lin k e d c o lla g e n v a s c u la r d is e a s e fr o m th e lis t p ro v id e d .

1. S y s te m ic v a s c u litis
2 . S k in r a s h
3. W id e s p r e a d c o n n e c tiv e tis s u e
fib r o s is
4. B u t te r fly r a s h o v e r t h e c h e e k s a n d
b r id g e o f n o s e
5. S tiff n e s s o f jo in ts
A . S y s te m ic lu p u s e r y th e m a to s u s
B . S c le r o d e r m a
C . P o ly a r te r itis n o d o s a
D . D e r m a to m y o s it is
E. R h e u m a to id a r th r it is

M IC R O B IO L O G Y /P A T H O L O G Y i * d e n ta ld e c k s
P a r t I • V o lu m e 1 3 - © 2 0 1 7
 1.C , 2.D , 3.B , 4 .A, 5.E
C o lla g e n is a to u g h , g lu e - lik e p r o te in th a t r e p r e s e n ts 3 0 % o f b o d y p r o te in . It s h a p e s
th e s tr u c tu r e o f te n d o n s , b o n e s , a n d c o n n e c tiv e tis s u e s . P ro b le m s w ith th e im m u n e
s y s te m c a n a ffe c t th e s e s tru c tu r e s . T h is is k n o w n a s c o lla g e n v a s c u la r d is e a s e .
C o llag en v a s c u la r d is e a s e s inclu d e:
• P o ly a rte ritis n od o sa: a s e r io u s b lo o d v e s s e l d is e a s e o f u n k n o w n c a u s e
c h a r a c te r iz e d b y n e c r o tiz in g im m u n e c o m p le x in fla m m a tio n o f s m a ll a n d m e d iu m
s iz e d a r te r ie s
° T h e r e is a n a s s o c ia tio n w ith h ep a titis B v ir a l in fe c tio n ; c lin ic o p a th o lo g ic
m a n ife s ta tio n s o f th e d is e a s e in c lu d e s y s te m ic v a s c u litis
• D e rm a to m y o s itis : a m u s c le d is e a s e th a t c a u s e s in fla m m a tio n a n d a s k in ra s h . It
is a ty p e o f in fla m m a to r y m y o p a th y
° T h e c a u s e is u n k n o w n
• S c le ro d e rm a : a w id e s p re a d c o n n e c tiv e tis s u e d is e a s e th a t in v o lv e s c h a n g e s in
th e s k in , b lo o d v e s s e ls , m u s c le s , a n d in te r n a l o r g a n s
° C o m m o n in y o u n g w o m e n
° W id e s p r e a d c o n n e c tiv e tis s u e fib r o s is
° T ig h t a n d m a s k - lik e fa c ia l s k in , R a y n a u d 's p h e n o m e n o n , p a in , s tiffn e s s , a n d
s w e llin g o f fin g e r s a n d jo in ts , G E R D , in c r e a s e d c h a n c e o f B a r re tt's e s o p h a g u s
• S y s te m ic lu p u s e ry th e m a to s u s (S L E ): th e p r o to ty p e c o n n e c tiv e tis s u e d is e a s e
° S L E ( lu p u s ) is a n a u to im m u n e d is e a s e
° 8 0 % o f S L E p a tie n ts a re w o m e n , u s u a lly th o s e o f c h ild b e a rin g a g e
» F e v e r, m a la is e , ly m p h a d e n o p a th y , a n d w e ig h t lo s s
« C h a ra c te r is tic b u tte r fly ra s h o v e r th e c h e e k s a n d b r id g e o f th e n o s e ( 5 0 % o f
p a tie n ts ) , jo in t p a in a n d a r th r itis , R a y n a u d 's p h e n o m e n o n
° E x te n s iv e im m u n e c o m p le x - m e d ia te d in fla m m a to r y le s io n s , th e le s io n s o f
g r e a te s t c lin ic a l im p o r ta n c e in S L E a r e th o s e in th e k id n e y
• R h eu m a to id a rth ritis (R A ): is a c h r o n ic s y s te m ic in fla m m a to r y d is o r d e r th a t
m a y a ffe c t m a n y tis s u e s o r o r g a n s - s k in , b lo o d v e s s e ls , h e a rt, lu n g s , a n d
m u s c le s - b u t p r in c ip a lly a tta c k s th e jo in ts
d is e a s e s 209

W h ic h o f th e fo llo w in g is th e m o s t c o m m o n d e m y e lin a tin g d is o r d e r ?

• D e v ic 's d is e a s e
• T a b e s d o r s a lis
• O p tic n e u r itis
• M u ltip le s c le r o s is
• G u illa in - B a r r e s y n d r o m e

M IC R O B IO L O G Y /P A T H O L O G Y W k d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • M u ltip le s c le ro s is
M u ltip le s c le ro s is (M S ) is a d is o r d e r o f th e b r a in a n d s p in a l c o rd ( c e n tr a l n e r v o u s
s y s te m ) c a u s e d b y p r o g re s s iv e d a m a g e to th e o u te r c o v e rin g o f n e r v e c e lls ( m y e lin ) .
T h is r e s u lts in d e c re a s e d n e r v e fu n c tio n in g w h ic h c a n le a d to a v a r ie ty o f s y m p to m s .
A lth o u g h th e c a u s e a n d p a th o g e n e s is o f th e d is e a s e r e m a in to b e e lu c id a te d , th e r e is
e v id e n c e th a t s u g g e s ts a n a u to im m u n e c o m p o n e n t to th e d is e a s e w ith C D 4 + a n d
C D 8 + T - c e ll in v o lv e m e n t. T h e d is e a s e in v o lv e s r e p e a te d e p is o d e s o f in fla m m a tio n o f
n e r v o u s tis s u e in a n y a r e a o f th e c e n tr a l n e r v o u s s y s te m ( b r a in a n d s p in a l c o rd ).
T h e s e e p is o d e s o c c u r w h e n th e b o d y 's o w n im m u n e c e lls a tta c k th e n e r v o u s s y s te m .
T h e lo c a tio n o f th e in fla m e d a r e a s v a r ie s fr o m p e r s o n to p e r s o n a n d fr o m e p is o d e to
e p is o d e . T h e in fla m m a tio n d e s tr o y s th e c o v e r in g o f th e n e r v e c e lls in th a t a r e a
( m y e lin s h e a th ) , le a v in g m u ltip le a r e a s o f s c a r tis s u e ( s c le r o s is ) a lo n g th e c o v e rin g o f
th e n e r v e c e lls . T h is r e s u lts in s lo w in g o r b lo c k in g th e tr a n s m is s io n o f n e r v e im p u ls e s
in th a t a r e a , le a d in g to th e s y m p to m s o f M S . C o m m o n s y m p to m s o f M S in c lu d e
v is u a l d is tu r b a n c e s , s p e e c h d is tu r b a n c e s , p a r e s th e s ia s ( tin g lin g , p ric k lin g , o r
n u m b n e s s ), d e p r e s s io n , m o o d s w in g s , e tc .
1. M S is th e m o st c o m m o n o f th e d e m y e lin a tin g d is o r d e r s , h a v in g a
p r e v a le n c e o f a p p ro x im a te ly 1 p e r 1 0 0 0 p e rs o n s .
2. T h e d is e a s e m a y b e c o m e c lin ic a lly a p p a r e n t a t a n y a g e , a lth o u g h o n s e t
in c h ild h o o d o r a fte r a g e 5 0 y e a r s is r e la tiv e ly ra re .
3. W o m e n a re a ffe c te d tw ic e a s o fte n a s a re m e n .
4. T h e le s io n s o f M S a re c a u s e d b y a n im m u n e re s p o n se th a t is d ir e c te d
a g a in s t th e c o m p o n e n ts o f th e m y e lin sh e a th .
5. M S is a w h ite m a tte r d is e a s e th a t is b e s t a p p re c ia te d in s e c tio n s o f th e
b r a in a n d s p in a l c o r d . L e s io n s a p p e a r a s m u ltip le , w e ll- c ir c u m s c r ib e d ,
s o m e w h a t d e p r e s s e d , g la s s y , g r a y -ta n , ir r e g u la r ly s h a p e d p laq u es.
6. M o d e r a te a m o u n ts o f p r o te in a n d a s m a ll n u m b e r o f ly m p h o c y te s in th e
c e r e b ro s p in a l flu id a re c h a r a c te r is tic o f M S .
7. In je c ta b le in te r fe r o n , a r e la tiv e ly n e w tr e a tm e n t, re d u c e s th e fr e q u e n c y of
re la p s e s o f M S .
d is e a s e s 2 10

In m a n y c a s e s o f p r im a r y a m y lo id o s is , th e p a tie n ts h a v e s o m e fo r m
o f:

• m a c r o p h a g e d y s c r a s ia
• e r y th r o c y te d y s c r a s ia
• h e m o g lo b in d y s c r a s ia
• p la s m a c e ll d y s c r a s ia

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n t a l decks
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • p la s m a cell d y s cras ia
“A m y lo id o s is ” is a g e n e r ic te r m u s e d to d e s c r ib e v a r io u s c o n d itio n s w h e r e
e x tr a c e llu la r d e p o s its o f m is fo ld e d p r o te in s (a m y lo id s ) c a u s e tis s u e d a m a g e a n d
c o m p r o m is e o r g a n fu n c tio n . T h e s e a m y lo id s a r e p r im a r ily c o m p o s e d o f in s o lu b le
fib r o u s p r o te in s ( s c le r o p r o te in ) . C h a r a c te r is tic a lly , th e a m y lo id p ro te in c o n s is ts o f
b e ta - p le a te d s h e e ts th a t a re r e s p o n s ib le fo r its in s o lu b ility a n d r e s is ta n c e to
p r o te o ly s is .
A m y lo id o s e s a re c la s s ifie d a c c o r d in g to th e p h y s ic a l a n d c h e m ic a l n a tu r e o f th e
a m y lo id p ro te in it is c o m p o s e d o f, a s w e ll a s to th e e x te n t o f th e d e p o s its : s y s te m ic
(m o r e th a n o n e o r g a n o r b o d y s y s te m is in v o lv e d ) o r lo c a liz e d ( s in g le o rg a n
in v o lv e m e n t). C lin ic a lly , th e s y s te m ic a n d lo c a liz e d d e s ig n a tio n s a re fu rth e r
c a te g o r iz e d in to e ith e r p rim a ry o r s e c o n d a ry , d e p e n d in g o n w h e th e r th e
a m y lo id o s is is re la te d to a n im m u n e d is e a s e ( p r im a r y ) o r a c o m p lic a tio n o f s o m e
o th e r c h r o n ic in fla m m a to r y p r o c e s s (s e c o n d a r y ) .
• P rim a ry a m y lo id o s is : c a u s e is u n k n o w n ; it is re la te d to a b n o r m a l p r o d u c tio n of
im m u n o g lo b u lin s b y m a lig n a n t p la s m a c e lls (i.e ., a s in m u ltip le m y e lo m a ) . It is
u s u a lly s y s te m ic in d is trib u tio n . T y p ic a l s ite s o f a m y lo id b u ild u p a re th e h e a rt,
lu n g s , s k in , to n g u e , th y r o id g la n d , in te s tin e s , liv e r, k id n e y , a n d b lo o d v e s s e ls .
• S ec o n d ary ( re a c tiv e ) s y s te m ic a m y lo id o s is : th e a m y lo id o s is is a c o m p lic a tio n
o f a n o th e r d is e a s e s u c h a s T B , r h e u m a to id a r th r itis , o r F a m ilia l M e d ite r ra n e a n
fe v e r . A m y lo id te n d s to b u ild u p in th e s p le e n , liv e r, k id n e y s , a d r e n a l g la n d s , a n d
ly m p h n o d e s . T h e h e a r t is r a r e ly in v o lv e d .
• H e re d ita ry a m y lo id o s is : m o s tly ra re a n d lim ite d to s p e c ific g e o g ra p h ic a re a s ,
th e s e a m y lo id o s e s a re th e re s u lt o f g e n e tic m u ta tio n s . F o r e x a m p le , F a m ilia l
M e d ite r ra n e a n fe v e r , s y s te m ic s e n ile a m y lo id o s is a n d s e v e r a l ty p e s o f fa m ilia l
a m y lo id o tic n e u r o p a th ie s .
N o te: A lz h e im e r 's d is e a s e , d ia b e te s m e llitu s ty p e 2 a n d P a r k in s o n 's d is e a s e a re
s o m e o th e r e x a m p le s o f a m y lo id a s s o c ia te d c o n d itio n s a s th e y a re a ll c h a r a c te r iz e d
b y d e p o s its o f a m y lo id . F o r e x a m p le , d ia b e te s m e llitu s ty p e 2 is c h a r a c te riz e d b y
d e p o s its o f a m y lo id ( re fe r r e d to a s a m y lin ) in is le t c e lls .
d is e a s e s 211

U r tic a r ia (h iv e s ) is a c o m m o n d is o r d e r o f th e s k in c h a r a c te r iz e d b y
lo c a liz e d m a s t c e ll d e g r a n u la tio n a n d r e s u lta n t d e r m a l m ic r o v a s c u la r
h y p e r p e r m e a b ility . T h is g iv e s r is e to p r u r it ic e d e m a to u s p la q u e s
c a lle d w h e a ls .
A n g io e d e m a is c lo s e ly re la te d to u r tic a r ia a n d is c h a r a c te r iz e d b y
d e e p e r e d e m a o f b o th th e d e r m is a n d th e s u b c u ta n e o u s fa t.

• b o th s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a rt I- V o lu m e 1 3 - © 2 0 1 7
 • b o th s ta te m e n ts a r e tr u e
U r t ic a r ia m o s t o fte n o c c u r s b e tw e e n a g e s 2 0 a n d 4 0 , a lt h o u g h a ll a g e g r o u p s
a r e s u s c e p tib le . In d iv id u a l le s io n s d e v e lo p a n d fa d e w it h in h o u r s ( u s u a lly < 2 4
h o u r s ) , a n d e p is o d e s m a y la s t f o r d a y s o r p e r s is t f o r m o n th s . L e s io n s m a y v a r y
fr o m s m a ll, p r u r it ic p a p u le s to la r g e e d e m a t o u s p la q u e s . S it e s o f p r e d ile c t io n
f o r u r tic a r ia l e r u p tio n s in c lu d e a n y a r e a e x p o s e d to p r e s s u r e , s u c h a s th e
tr u n k , d is ta l e x tr e m itie s , a n d e a r s .
In m o s t c a s e s , u r tic a r ia r e s u lts fr o m a n tig e n -in d u c e d r e le a s e o f v a s o a c tiv e
m e d ia to r s fr o m m a s t c e ll g r a n u le s th r o u g h s e n s it iz a t io n w ith s p e c if ic Ig E
a n tib o d ie s . T h is Ig E -d e p e n d e n t r e a c t io n c a n f o llo w e x p o s u r e to m a n y d if fe r e n t
a n t ig e n s ( p o lle n s , f o o d s , d r u g s , in s e c t v e n o m ) . Ig E - in d e p e n d e n t u r tic a r ia
m a y a ls o r e s u lt fr o m s u b s t a n c e s t h a t in c e r ta in in d iv id u a ls d ir e c t ly in c it e th e
d e g r a n u la t io n o f m a s t c e lls , s u c h a s o p ia te s , c e r t a in a n tib o d ie s , a n d c u r a r e .
A n o t h e r c a u s e o f Ig E -in d e p e n d e n t u r tic a r ia is e x p o s u r e to c h e m ic a ls , s u c h a s
a s p ir in , th a t s u p p re s s p r o s t a g la n d in s y n t h e s is fr o m a r a c h id o n ic a c id .
C o m p le m e n t - m e d ia t e d u r tic a r ia is s e e n in h e r e d ita r y a n g io n e u r o tic
e d e m a , c a u s e d b y a n in h e r ite d d e fi c ie n c y o f C l in h ib it o r t h a t r e s u lts in
u n c o n tr o lle d a c t iv a t io n o f t h e e a r ly c o m p o n e n t s o f t h e c o m p le m e n t s y s t e m a n d
p r o d u c tio n o f v a s o a c t iv e m e d ia to r s .
It c h in g is u s u a lly t h e f ir s t s y m p to m o f h iv e s , q u ic k ly f o llo w e d b y w h e a ls -
s m o o th , s lig h t ly e le v a te d a r e a s t h a t a r e r e d d e r o r p a le r t h a n t h e s u r r o u n d in g
s k in a n d u s u a lly r e m a in s m a ll. W it h a n g io e d e m a , t h e s w e llin g o fte n c o v e r s
la r g e a r e a s a n d e x te n d s d e e p b e n e a th th e s k in . It m a y in v o lv e p a r t o r a ll o f th e
h a n d s , fe e t, e y e lid s , lip s , o r g e n it a ls o r e v e n th e lin in g o f th e m o u th , th r o a t ,
a n d a ir w a y s , m a k in g b r e a th in g d if fic u lt .
Im p o r ta n t: The r e le a s e o f h is ta m in e a n d o t h e r c h e m ic a ls in t o th e
b lo o d s tr e a m ( a lle r g ic r e s p o n s e ) c a u s e s t h e itc h in g , lo c a liz e d s w e llin g , and
o th e r s y m p to m s .
d is e a s e s 212

T y p e 1 d ia b e te s is c a u s e d b y a re d u c tio n in s e n s itiv ity o f in s u lin 's

ta r g e t c e lls .
T y p e 1 d ia b e te s is m o r e c o m m o n th a n ty p e 2 d ia b e te s .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta t e m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta id e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • b o th s ta te m e n ts a re fa ls e
D ia b e te s m e llit u s is n o t a s in g le d is e a s e e n tity b u t r a th e r a g r o u p o f m e ta b o lic
d is o r d e r s s h a r in g th e com m on u n d e r ly in g fe a tu r e of h y p e r g ly c e m ia .
H y p e r g ly c e m ia in d ia b e te s r e s u lt s fr o m d e fe c ts in in s u lin s e c r e tio n , in s u lin
a c tio n , o r , m o s t c o m m o n ly , b o th . T h e c la s s ic tr ia d o f s y m p to m s in c lu d e s
p o ly d ip s ia , p o ly u r ia , a n d p o ly p h a g ia .
T y p e 1 d ia b e te s is a n a u to im m u n e d is e a s e c h a r a c te r iz e d b y p a n c r e a tic (3-cell
d e s tr u c tio n a n d a n a b s o lu te d e fic ie n c y o f in s u lin .
T y p e 2 d ia b e te s is c a u s e d b y a c o m b in a tio n o f p e r ip h e r a l r e s is ta n c e to in s u lin
a c tio n a n d a n in a d e q u a te s e c r e to r y r e s p o n s e b y th e p a n c r e a tic [3 -c e lls ( " r e la tiv e
in s u lin d e fic ie n c y ” ).
* * * m a n a g e m e n t o f e it h e r c o n d it io n c a n b e m o n ito r e d in th e s h o r t te r m b y lo o k in g
b lo o d g lu c o s e le v e ls o r ( lo n g te r m ) H b l A C le v e ls . T y p ic a lly , n o r m a l b lo o d
s u g a r s s h o u ld b e < 1 1 0 m g /d l ( f a s t in g ) a n d H b l A C s h o u ld b e < 6 % .
C o m p a r is o n o f T y p e 1 a n d T y p e 2 D i a b e te s M e llitu s

C h a ra c te ris tic T y p e 1 T y p e 2

L e v e l o f in s u lin s e c r e tio n N one o r alm ost none M ay be norm al or exceed norm al

T y p ic a l a g e o f o n se t Childhood A dulthood

P e rc e n ta g e o f d ia b e te s 5% to 10% 90% to 95%

B a s ic d e fe c t D estruction o fb e t a cells R educed sensitivity o f in s ulin's targ et cells

A s s o c ia te d w ith o b e s ity No U sually

S p e e d o f d e v e lo p m e n t o f s y m p to m s Rapid Slow

D e v e lo p m e n t o f k e to s is C om m on if untreated Rare

T r e a tm e n t Insulin injections, dietary Dietary' control and w eight reduction,

m anagem ent occasionally oral hypoglycem ic drugs
d is e a s e s 213

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith

r h e u m a to id a r th r it is .

• jo in t e ffu s io n s
• B o u c h a r d 's n o d e s
• b a c te r ia l in n a t u r e
• fu n g a l in n a tu r e
• S till's d is e a s e
• o s te o p h y te
• unknow n cause

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c l< s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • jo in t e ffu s io n s
• S till's d is e a s e
• u n k n o w n c au se
R h e u m a to id a r th r itis (R A ) is a c h ro n ic s y s te m ic in fla m m a to r y d is o r d e r th a t m a y a ffe c t
m a n y tis s u e s o r o rg a n s - s k in , b lo o d v e s s e ls , h e a rt, lu n g s , a n d m u s c le s - b u t
p r in c ip a lly a tta c k s th e jo in ts , p ro d u c in g a n o n s u p p u r a tiv e p ro life ra tiv e a n d
in fla m m a to r y s y n o v itis th a t o fte n p r o g r e s s e s to d e s tr u c tio n o f th e a r tic u la r c a rtila g e
a n d a n k y lo s is o f th e jo in ts . A lth o u g h th e c a u s e o f rh e u m a to id a r th r itis re m a in s
u n kn o w n , g e n e tic p re d is p o s itio n , e n v iro n m e n t, a n d a u to im m u n ity h a v e p iv o ta l ro le s in
th e d e v e lo p m e n t, p ro g re s s io n , a n d c h r o n ic ity o f th e d is e a s e .
W o m e n a re a ffe c te d th r e e to fiv e tim e s m o re o fte n th a n m e n . It is m o s t c o m m o n in
th o s e 4 0 to 7 0 y e a rs o ld , b u t n o a g e is im m u n e . T h e c o u rs e a n d th e s e v e rity o f th e
illn e s s c a n v a ry c o n s id e ra b ly . N o te: S till's d is e a s e is a ty p e o f R A th a t o c c u r s in
y o u n g p e o p le .
R A a rth ritis h a s a d is p o s itio n to a ffe c t m e ta c a r p o p h a la n g e a l M C P jo in ts , a n d P IP
(p ro x im a l in te rp h a la n g e a l jo in ts ).
T h e o n s e t o f th e d is e a s e is u s u a lly g ra d u a l, w ith fa tig u e , m o rn in g s tiffn e s s (la s tin g
m o re th a n o n e h o u r), d iffu s e m u s c u la r a c h e s , lo s s o f a p p e tite , a n d w e a k n e s s .
E v e n tu a lly , jo in t p a in a p p e a rs , w ith w a rm th , s w e llin g , te n d e r n e s s , a n d s tiffn e s s o f th e
jo in t a fte r in a c tiv ity . T h e p a tte rn of jo in t in v o lv e m e n t v a rie s , b u t it is g e n e ra lly
s y m m e trica l a n d th e s m all jo in ts a re a ffe c te d b e fo re th e la rg e r o n e s . S y m p to m s
u s u a lly d e v e lo p in th e h a n d s a n d fe e t, fo llo w e d b y th e w ris ts , a n k le s , e lb o w s , a n d
k n e e s . Note: T h e ra d io g ra p h ic h allm a rk s a re jo in t e ffu s io n s a n d ju x ta - a r tic u la r
o s te o p e n ia w ith e r o s io n s a n d n a rro w in g o f th e jo in t s p a c e w ith lo ss o f a rtic u la r
c a rtila g e.
1. Im p o rtan t: R A is m a rk e d b y a p ro lifera tiv e in fla m m a tio n o f th e s y n o v ia l
m e m b ra n e s , le a d in g to d e fo r m ity , a n k y lo s is , a n d in v a lid is m .
2. R em em b er: O s te o p h y te (b o n y s p u r) fo r m a tio n is a c a rd in a l fe a tu r e of
o s te o a rth ritis , n ot rh e u m a to id a rth ritis .
3. R h e u m a to id a rth ritis , s y s te m ic lu p u s e r y th e m a to s u s , p o ly a r te r itis n o d o s a ,
d e r m a to m y o s itis , a n d s c le r o d e r m a a re a ll c la s s ifie d a s c o lla g en
d is e a s e s . T h e y a ll h a v e in c o m m o n in fla m m a to ry d a m ag e to c o n n e c tiv e
tis s u e s a n d b lo o d v e s s e ls w ith th e d e p o s itio n o f fib rin o id m aterial.
d is e a s e s 214

W h ic h o f th e fo llo w in g is th e p r o to ty p e o f a s y s te m ic im m u n e
c o m p le x d is e a s e ?

• s y s te m ic lu p u s e r y th e m a to s u s
• a c u te s e r u m s ic k n e s s
• p o s ts tr e p to c o c c a l g lo m e r u lo n e p h r itis
• r e a c tiv e a r th r itis

• p o ly a r t e r it is n o d o s a

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a c u te s eru m s ickn ess
T y p e III h y p e rs e n s itiv ity r e a c tio n s a re c a u s e d b y s o lu b le im m u n e c o m p le x e s
fo r m e d b y th e b in d in g o f IgG to th e s o lu b le a n tig e n s a g a in s t w h ic h th e y w e r e m a d e .
T h e s iz e o f im m u n e c o m p le x e s d e p e n d s o n th e re la tiv e c o n c e n tr a tio n s o f a n tig e n a n d
a n tib o d y . L a rg e im m u n e c o m p le x e s a re c le a r e d b y p h a g o c y te s b e a r in g F c a n d
c o m p le m e n t r e c e p to r s . S m a ll s o lu b le im m u n e c o m p le x e s te n d to b e d e p o s ite d o n
th e w a lls o f s m a ll b lo o d v e s s e ls , w h e r e th e y a c tiv a te c o m p le m e n t a n d in fla m m a tio n .
D e p e n d in g o n th e s ite s o f a c tiv a tio n , th e s e r e a c tio n s c a n c a u s e v a s c u litis , n e p h ritis ,
a r th r itis , o r lu n g d is e a s e . R e m e m b er: H is ta m in e d o es n ot p la y a m a jo r ro le in th e s e
T y p e III h y p e r s e n s itiv ity re a c tio n s .
Im m u n e c o m p le x -m e d ia te d d is e a s e s c a n b e s y s te m ic , if im m u n e c o m p le x e s a re
fo r m e d in th e c irc u la tio n a n d a re d e p o s ite d in m a n y o rg a n s , o r lo c a lize d to p a r tic u la r
o r g a n s , s u c h a s th e k id n e y ( g lo m e r u lo n e p h r itis ) , jo in ts (a r th r itis ) o r th e s m a ll b lo o d
v e s s e ls o f th e s k in ( v a s c u litis ) . T h e p a th o g e n e s is o f s y s te m ic im m u n e c o m p le x
d is e a s e c a n b e d iv id e d in to th r e e p h a s e s : (1 ) fo r m a tio n o f a n tig e n -a n tib o d y
c o m p le x e s in th e c ir c u la tio n ; (2 ) d e p o s itio n o f th e im m u n e c o m p le x e s in v a r io u s
tis s u e s , th u s in itia tin g (3) a n in fla m m a to r y re a c tio n a t th e s ite s o f im m u n e c o m p le x
d e p o s itio n .
ICxampIcs o f Im m u n e C o m p lex -M e d ia te d D iseases

D is e a s e A n tig e n in v o lv e d C lin ic o p a th o l o g ic M a n if e s ta tio n s

S y s te m ic lu p u s e r y th e m o to s u s N u c le a r a n tig e n s N e p h ritis , s k in le s io n s , a r th ritis , o th e rs

P o s ts tre p to c o c c a l g lo m e ru lo n e p h ritis S tre p to c o c c a l c e ll w a ll a n tig e n (s ); m a y b e N e p h ritis

" p la n te d " i n g lo m e r u la r b a s e m e n t m e m b ra n e

P o ly a rte ritis n o d o s a 1 le p a titis B v iru s a n tig e n s in s o m e c a s e s S y s te m ic v a s c u litis

R e a c tiv e a rth ritis B a cte ria l a n tig e n s (c .g .. Y e rsin ia ) A c u te a rth ritis

S c ru m s ic k n e s s V ario u s p ro te in s , c .g ., lo re ig n s c ru m p ro te in A r th ritis , v a s c u litis , n e p h ritis

(h o rs e a n ti- th y m o c y te g lo b u lin )

A rth u s re ac tio n V a rio u s fo reig n p r o te in s C u ta n e o u s v a s c u litis

d is e a s e s 215

_ _ _ _ _ _ _ _ h y p e r s e n s itiv ity r e a c tio n s a re in itia te d b y a n tig e n -a c tiv a te d

(s e n s itiz e d ) T ly m p h o c y te s , in c lu d in g C D 4 + a n d C D 8 + T c e lls .

• ty p e I
• ty p e II
• ty p e III
• ty p e IV

M IC R O B IO L O G Y /P A T H O L O G Y tM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • typ e IV
H y p e rs e n s itiv ity re fe r s to u n d e s ira b le (d a m a g in g , d is c o m fo r t-p r o d u c in g a n d s o m e tim e s
fa ta l) re a c tio n s p ro d u c e d b y th e n o rm a l im m u n e s y s te m . H y p e rs e n s itiv ity re a c tio n s r e q u ire
a p re -s e n s itiz e d ( im m u n e ) s ta te o f th e h o s t. H y p e rs e n s itiv ity re a c tio n s c a n b e d iv id e d in to
fo u r ty p e s : ty p e I, ty p e II, ty p e ill, a n d ty p e IV, b a s e d o n th e m e c h a n is m s in v o lv e d a n d
tim e ta k e n fo r th e re a c tio n .
C lassification of hyp ersen sitivity reactions:
• T yp e I (a ls o k n o w n a s im m e d ia te o r a n a p h y la c tic h y p e rs e n s itiv ity ) a re re a c tio n s in
w h ic h a n tig e n s ( a lle r g e n s ) c o m b in e w ith s p e c ific IgE a n tib o d ie s th a t a re b o u n d to
m e m b r a n e r e c e p to r s o n tis s u e m a s t c e lls a n d b lo o d b a s o p h ils . T h e a n tig e n -a n tib o d y
re a c tio n c a u s e s th e ra p id re le a s e o f p o te n t v a s o a c tiv e a n d in fla m m a to r y m e d ia to rs ,
w h ic h m a y b e p re fo r m e d ( e .g ., h is ta m in e , tr y p ta s e , k in in o g e n a s e ) o r n e w ly g e n e r a te d
fro m m e m b r a n e lip id s (e .g ., th e le u k o trie n e s B 4 , C 4 , a n d D 4 , p r o s ta g la n d in s D 2 , a n d
P A F ). E x a m p le s in c lu d e : A lle r g ic rh in itis , a s th m a , a n d a n a p h y la x is .
• T yp e II a re c y to to x ic re a c tio n s r e s u ltin g w h e n a n tib o d y re a c ts w ith a n tig e n ic
c o m p o n e n ts o f a c e ll o r tis s u e e le m e n ts (o r w ith a n tig e n o r h a p te n ) th a t is c o u p le d to a
c e il o r tis s u e . T h e a n tig e n -a n tib o d y re a c tio n m a y a c tiv a te c e rta in c y to to x ic c e lls (k ille r T
-c e lls o r m a c r o p h a g e s ) to p ro d u c e a n tib o d y -d e p e n d e n t cell-m ed iated cytotoxicity.
T y p e II h y p e rs e n s itiv ity is p rim a r ily m e d ia te d b y a n tib o d ie s o f th e Ig M o r Ig G c la s s e s
a n d c o m p le m e n t. E x a m p le s in c lu d e : G o o d p a s tu r e 's s y n d r o m e , e ry th r o b la s to s is fe ta lis ,
a u to im m u n e h e m o ly tic a n e m ia , a n d h y p e ra c u te tr a n s p la n t re je c tio n .
• T yp e III a re im m u n e c o m p le x (1C) re a c tio n s ( m o s tly o f th e Ig G c la s s ) re s u ltin g fro m
d e p o s itio n o f s o lu b le c irc u la tin g a n tig e n -a n tib o d y IC s in v e s s e ls o r tis s u e . P rim a ry
c o m p o n e n ts a re s o lu b le im m u n e c o m p le x e s a n d c o m p le m e n t (C 3 a , 4 a , a n d 5 a ). T h e
d a m a g e is c a u s e d b y p la te le ts a n d n e u tro p h ils . T h e le s io n c o n ta in s p rim a r ily
n e u tro p h ils a n d d e p o s its o f im m u n e c o m p le x e s a n d c o m p le m e n t. M a c r o p h a g e s
in filtr a tin g in la te r s ta g e s m a y b e in v o lv e d in th e h e a lin g p ro c e s s . E x a m p le s in c lu d e :
S e ru m s ic k n e s s , s y s te m ic lu p u s e ry th e m a to s u s , a n d A r th u s r e a c tio n .
• T yp e IV h y p e rs e n s itiv ity is a ls o k n o w n a s cell m ediated o r d elayed type
h y p e rs e n s itiv ity . T h e s e r e a c tio n s a re in itia te d b y a n tig e n -a c tiv a te d ( s e n s itiz e d ) T
ly m p h o c y te s , in c lu d in g C D 4 + a n d C D 8 + T c e lls . T h e c la s s ic a l e x a m p le o f th is
h y p e rs e n s itiv ity is tub erc ulin (M o n to u x ) reaction. C irc u la tin g a n tib o d ie s are not
in v o lv e d in n o r a re th e y n e c e s s a r y fo r d e v e lo p m e n t o f tis s u e in ju ry . E x a m p le s
in c lu d e : C o n ta c t d e r m a titis , tu b e rc u lin te s t, a n d c h ro n ic tr a n s p la n t re a c tio n .
d is e a s e s 216

W h ic h o f t h e fo llo w in g a n tib o d ie s a r e s p e c ific fo r s y s te m ic lu p u s

e r y th e m a to s u s ?

• a n ti- S m
• a n ti- J o
• a n ti- R o
• a n ti- c e n tr o m e r e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • a n ti-S m
S L E is th e p r o to ty p e o f a m u ltis y s te m d is e a s e o f a u to im m u n e o r ig in , c h a ra c te r iz e d b y
a v a s t a r ra y o f a u to an tib o d ie s , p a r tic u la r ly a n tin u c le a r a n tib o d ie s (A N A s ) . A c u te
o r in s id io u s in its o n s e t, it is a c h r o n ic , r e m ittin g a n d re la p s in g , o fte n fe b rile illn e s s
c h a ra c te r iz e d p r in c ip a lly b y in ju r y to th e s k in , jo in ts , k id n e y , a n d s e r o s a l m e m b r a n e s .
N o te: A n ti-D N A a n d a n ti-S m a n tib o d ie s a p p e a r to b e s p e c ific fo r S L E .
P a tie n ts w ith lu p u s p r o d u c e a b n o rm a l a n tib o d ie s in th e ir b lo o d th a t ta r g e t tis s u e s
w ith in th e ir o w n b o d y r a th e r th a n fo r e ig n in fe c tio u s a g e n ts . B e c a u s e th e a n tib o d ie s
a n d a c c o m p a n y in g c e lls o f in fla m m a tio n c a n in v o lv e tis s u e s a n y w h e r e in th e b o d y ,
lu p u s h a s th e p o te n tia l to a ffe c t a v a r ie ty o f a r e a s o f th e b o d y . S o m e tim e s lu p u s c a n
c a u s e d is e a s e o f th e s k in , h e a rt, lu n g s , k id n e y s , jo in ts , a n d /o r n e r v o u s s y s te m . W h e n
o n ly th e s k in is in v o lv e d , th e c o n d itio n is c a lle d d is c o id lu p u s . W h e n in te r n a l o r g a n s
a r e in v o lv e d , th e c o n d itio n is c a lle d s y s te m ic lu p u s e ry th e m a to s u s (SLE). B o th
d is c o id a n d s y s te m ic lu p u s a r e m o r e c o m m o n in w o m e n th a n m e n ( a b o u t e ig h t tim e s
m o r e c o m m o n ) . T h e d is e a s e c a n a ffe c t a ll a g e s b u t m o s t c o m m o n ly b e g in s b e tw e e n
th e a g e s o f 2 0 to 4 5 y e a rs .
A t its o n s e t, o n ly o n e o r g a n s y s te m m a y b e in v o lv e d . A d d itio n a l o r g a n s m a y b e c o m e
in v o lv e d la te r . R en al fa ilu r e c o m m o n ly o c c u r s a n d is th e u s u a l c a u s e o f d e a th .
S e v e r e C N S in v o lv e m e n t m a y a p p e a r. A c ro c y a n o sis ( R a y n a u d 's p h e n o m e n o n ) is
often a s s o c ia te d w ith S L E .
1. T h e c h a ra c te r is tic "b u tterfly" ra s h o v e r th e c h e e k s a n d b r id g e o f th e
n o s e a ffe c ts a b o u t h a lf o f th o s e w ith S L E . T h e ra s h is u s u a lly w o r s e n e d
b y s u n lig h t.
2. T h e p r e c is e r e a s o n fo r th e a b n o r m a l a u to im m u n ity th a t c a u s e s lu p u s is
not know n.
3. D o z e n s o f m e d ic a tio n s h a v e b e e n r e p o r te d to tr ig g e r S L E ; h o w e v e r ,
m o r e th a n 9 0 % o f th is "d ru g -in d u ce d lu p u s" o c c u r s a s a s id e e ffe c t o f
o n e o f th e fo llo w in g s ix d r u g s : h y d r a la z in e ( u s e d fo r h ig h b lo o d
p r e s s u r e ) , q u in id in e a n d p ro c a in a m id e ( u s e d fo r a b n o r m a l h e a r t rh y th m ) ,
p h e n y to in ( u s e d fo r e p ile p s y ), is o n ia z id [( N y d r a z id , L a n ia z id ), u s e d fo r
tu b e r c u lo s is ], p e n ic illa m in e ( u s e d fo r r h e u m a to id a r th r itis ) . T h e s e d r u g s
a r e k n o w n to s tim u la te th e im m u n e s y s te m a n d c a u s e S L E .
d is e a s e s 217

W h ic h o f th e fo llo w in g a u to im m u n e d is o r d e r s a r e c a u s e d b y th e
p r o d u c tio n o f a n tib o d ie s a g a in s t th e a c e ty lc h o lin e r e c e p to r w h ic h
r e s u lts in th e in h ib itio n o f n e u r o m u s c u la r tr a n s m is s io n a n d e v e n tu a l
p a ra ly s is ?

• E a to n - L a m b e r t s y n d r o m e
• m y a s th e n ia g r a v is
• G r a v e s ' d is e a s e
• A d d is o n 's d is e a s e
• H a s h im o to 's th y r o id itis

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • m y a s th e n ia g r a v is
M y a s th e n ia g r a v is ( M G ) is a n e u r o m u s c u la r d is o r d e r c h a r a c t e r iz e d b y
v a r ia b le w e a k n e s s o f v o lu n t a r y m u s c le s , w h ic h o fte n im p r o v e s w ith r e s t a n d
w o r s e n s w it h a c tiv it y . T h e c o n d it io n is c a u s e d b y a n a b n o r m a l im m u n e
re s p o n s e . The im m u n e s y s te m p ro d u c e s a n t ib o d ie s th a t a tta c k th e
a c e t y lc h o lin e r e c e p to r s ( A C h R s ) t h a t lie o n t h e m u s c le s id e o f th e
n e u r o m u s c u la r ju n c t io n . T h is d e c r e a s e s t h e r e s p o n s iv e n e s s o f t h e m u s c le
f ib e r s to a c e t y lc h o lin e r e le a s e d fr o m m o t o r n e u r o n e n d in g s . P a tie n ts w ith
m y a s t h e n ia g r a v is h a v e a h ig h e r r is k o f h a v in g o t h e r a u t o im m u n e d is o r d e r s
lik e t h y r o t o x ic o s is , r h e u m a t o id a r th r itis , a n d s y s t e m ic lu p u s e r y th e m a to s u s .
E a to n -L a m b e r t s y n d r o m e is s im ila r to m y a s t h e n ia g r a v is in t h a t it is a ls o a n
a u t o im m u n e d is e a s e th a t c a u s e s w eakness. H o w e v e r, E a to n -L a m b e rt
s y n d r o m e is c a u s e d b y t h e in a d e q u a te r e le a s e o f a c e t y lc h o lin e r a t h e r th a n
b y a b n o r m a l a n t ib o d ie s t o a c e t y lc h o lin e r e c e p to r s .
„„ 1. M G a ff e c ts a b o u t 3 o f e v e r y 1 0 ,0 0 0 p e o p le . W h e n a r is in g b e fo r e
a g e 4 0 y e a r s it is m o s t c o m m o n ly s e e n in w o m e n , b u t it o c c u r s
e q u a lly in b o th s e x e s in o ld e r p a tie n ts .
2 . A b o u t 1 0 % o f M G p a tie n ts d e v e lo p a life - th r e a te n in g w e a k n e s s o f
t h e m u s c le s n e e d e d f o r b r e a th in g (a c o n d it io n c a lle d “ m y a s t h e n ic ”
c r is is ) .
3 . T h y m ic h y p e r p la s ia is f o u n d in 6 5 % a n d t h y m o m a in 1 5 % o f
a ff e c te d p a tie n ts .
4 . In m o s t in s t a n c e s t h e a u to a n t ib o d ie s a g a in s t t h e A C h R le a d t o lo s s
o f f u n c t io n a l A C h R s a t t h e n e u r o m u s c u la r ju n c t io n b y ( 1 ) fix in g
c o m p le m e n t a n d c a u s in g d ir e c t in ju r y to th e p o s t s y n a p t ic
m e m b r a n e , (2 ) in c r e a s in g th e in t e r n a liz a t io n a n d d e g r a d a t io n o f th e
r e c e p to r s , a n d ( 3 ) in h ib it in g b in d in g o f a c e ty lc h o lin e .
d is e a s e s 218

In p h e n y lk e to n u r ia , ty r o s in e c a n n o t b e s y n th e s iz e d in a d e q u a te
a m o u n ts .
N e w b o r n s w ith p h e n y lk e to n u r ia d o n 't h a v e a n y s y m p to m s .

• b o th s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• t h e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s ta t e m e n t s a r e tr u e

E nzym e D eficiency D iseases

D ise as e C a u s e o r E n z y m e T h a t is D e fic ie n t R e s u lts o f D e fic ie n c y

Phenylketonuria Phenylalanine hydroxylase A ppearance o f phenylalanine and its degradation

products (e.g.. phenylketones) in the urine

M aple syrup urine A lpha-kcto acid dehydrogenase B ranched am ino acids (valine, isoleucinc, and leucine)
disease are excreted in the urine

A lcaptonuria H om ogentisic acid oxidase O xidized products o f hom ogentisic acid give urine a
dark color

Cystinuria D eficiency o f the intestinal and Kidney stones

kidney transport protein o f cysteine

A lbinism Tyrosinase D efect o f m elanin production that results in partial or

full absence o f pigm entation

1 . N e w b o r n s w it h p h e n y lk e t o n u r ia d o n 't h a v e a n y s y m p t o m s . W it h o u t
tr e a t m e n t , t h o u g h , b a b ie s u s u a lly d e v e lo p s ig n s o f P K U w it h in a
f e w m o n th s .
2 . P h e n y la la n in e is a n e s s e n tia l a m in o a c id .
3 . T y r o s in e is p r o d u c e d b y h y d r o x y la t io n o f th e e s s e n tia l a m in o a c id
p h e n y la la n in e .
4 . In p h e n y lk e t o n u r ia , ty r o s in e c a n n o t b e s y n t h e s iz e d in a d e q u a t e
a m o u n t s a n d is r e q u ir e d in t h e d ie t.
d is o r d e r s 219

In c r e a s e d m e la n in p ig m e n ta tio n is s e e n in:

• A d d is o n 's d is e a s e
• ja u n d ic e
• a lb in is m
• v itilig o
• h e m o s id e r o s is

M IC R O B IO L O G Y /P A T H O L O G Y d M e n t a ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 A d d is o n 's d is e a s e
A c c u m u la tio n s o f e n d o g e n o u s p ig m e n ts :
• M e la n in is a n e n d o g e n o u s , n o n - h e m o g lo b in d e r iv e d , b r o w n - b la c k p ig m e n t
fo r m e d w h e n th e e n z y m e ty r o s in a s e c a ta ly z e s th e o x id a tio n o f ty r o s in e to
d ih y d r o x y p h e n y la la n in e in m e la n o c y te s . F o r p r a c tic a l p u r p o s e s m e la n in is
th e o n ly e n d o g e n o u s b r o w n - b la c k p ig m e n t. T h e o n ly o th e r th a t c o u ld b e
c o n s id e r e d in th is c a te g o r y is h o m o g e n tis ic a c id , a b la c k p ig m e n t th a t
o c c u r s in p a tie n ts w it h a lk a p to n u r ia , a r a r e m e ta b o lic d is e a s e . H e r e th e
p ig m e n t is d e p o s it e d in th e s k in , c o n n e c tiv e t is s u e , a n d c a r tila g e , a n d th e
p ig m e n ta tio n is k n o w n a s o c h r o n o s is .
° In c r e a s e d m e la n in p ig m e n ta tio n is s e e n in A d d is o n 's d is e a s e
° D e c re a s e d m e la n in p ig m e n ta tio n is s e e n in a lb in is m a n d v it ilig o
• B ilir u b in is th e n o r m a l m a jo r p ig m e n t fo u n d in b ile . It is d e r iv e d fr o m
h e m o g lo b in b u t c o n ta in s n o ir o n . Its n o r m a l fo r m a tio n a n d e x c r e tio n a r e v ita l
to h e a lth , a n d ja u n d ic e is a c o m m o n c lin ic a l d is o r d e r c a u s e d b y e x c e s s e s o f
th is p ig m e n t w it h in c e lls a n d tis s u e s .
• H e m o s id e r in is a h e m o g lo b in - d e r iv e d , g o ld e n y e llo w - to - b r o w n , g r a n u la r o r
c r y s ta llin e p ig m e n t th a t s e r v e s a s o n e o f th e m a jo r s to r a g e fo r m s o f ir o n .
U n d e r n o r m a l c o n d itio n s s m a ll a m o u n ts o f h e m o s id e r in c a n b e s e e n in th e
m o n o n u c le a r p h a g o c y te s o f th e b o n e m a r r o w , s p le e n , a n d liv e r , w h ic h a re
a c tiv e ly e n g a g e d in r e d b lo o d c e ll b r e a k d o w n . L o c a l o r s y s te m ic e x c e s s e s o f
iro n c a u s e h e m o s id e r in to a c c u m u la te w it h in c e lls . L o c a l e x c e s s e s r e s u lt
fr o m h e m o r r h a g e s in tis s u e s . T h e b e s t e x a m p le o f lo c a liz e d h e m o s id e r o s is
is th e c o m m o n b r u is e . W h e n t h e r e is s y s te m ic o v e r lo a d o f ir o n , h e m o s id e r in
m a y b e d e p o s it e d in m a n y o r g a n s a n d tis s u e s , a c o n d it io n c a lle d
h e m o s id e r o s is . In m o s t in s ta n c e s o f s y s te m ic h e m o s id e r o s is th e p ig m e n t
d o e s n o t d a m a g e th e p a r e n c h y m a l c e lls o r im p a ir o r g a n fu n c tio n . N o te :
H e m o c h r o m a to s is is a n in h e r it e d c o n d it io n w h ic h is t h e r e a r e e x tr e m e
a c c u m u la tio n s o f ir o n a n d is a s s o c ia te d w ith liv e r , h e a r t, a n d p a n c r e a tic
d a m a g e , r e s u ltin g in liv e r fib r o s is , h e a r t fa ilu r e , a n d d ia b e te s m e llitu s .
d is o rd e rs 220

G o u t is c a u s e d b y a d e fe c t in m e ta b o lis m th a t r e s u lt s in an
o v e r p r o d u c tio n o f w h ic h o f th e fo llo w in g ?

• u re a
• a m m o n ia

• b ilir u b in
• u r ic a c id

M ICRO BIOLOGY/PATHOLOGY l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • uric acid
G o u t is a n inherited disorder of purine m etabolism o c c u r rin g p r e d o m in a n tly in m e n .
It is c a u s e d b y a d e fe c t in m e ta b o lis m th a t re s u lts in a n o v e r p r o d u c tio n o f u ric a c id , o r
a r e d u c e d a b ility of th e k id n e y to e lim in a te u ric a c id ( a lm o s t 2 5 % o f a ll p e o p le w h o
h a v e g o u t d e v e lo p k id n e y s to n e s ). T h e e x a c t c a u s e of th e m e ta b o lic d e fe c t is
u n k n o w n . T h e c o n d itio n m a y a ls o d e v e lo p in p e o p le w ith d ia b e te s , o b e s ity , s ic k le c e ll
a n e m ia , a n d k id n e y d is e a s e , o r it m a y fo llo w d ru g th e r a p y th a t in te r fe r e s w ith u ric a c id
e x c re tio n . G o u t h a s b e e n s tr o n g ly a s s o c ia te d w ith d e fe c ts in p u r in e m e ta b o lis m .
G o u t is c h a r a c te r iz e d b y th e d e p o s itio n o f m onosodium urate crystals in jo in ts a n d
o th e r tis s u e s a s a re s u lt o f hyperuricem ia. T h e d is o r d e r o c c u r s m o s t fr e q u e n tly in th e
m etatarsophalangeal jo in t of the big toe. A c u te g o u ty a r th r itis in th is c h a r a c te r is tic
lo c a tio n is k n o w n a s podagra. T h e in s te p , a n k le , k n e e , w r is t a n d e lb o w a re c o m m o n
s ite s , s o m e tim e s e v e n th e s p in e . B o u ts m a y v a r y fro m d a y s a p a r t to s e v e ra l a tta c k s a
y e a r; th e firs t a tta c k s m a y b e in o n ly o n e jo in t, la s tin g fo r d a y s . L a te r a tta c k s m a y
a ffe c t m o re jo in ts ; th e r e m a y b e jo in t d e fo r m a tio n if u n a tte n d e d . L im ita tio n o f jo in t
m o v e m e n t is p re c ip ita te d b y s tr e s s o r w r o n g d ie t. S y m p to m s in c lu d e a s h a rp , n e e d le ­
lik e p a in o n m o v e m e n t o f jo in ts ; s k in is te n s e , h o t, s h in y a n d d u s k y re d o r p u rp lis h ;
s y s te m ic r e a c tio n s m a y in c lu d e fe v e r, h e a r t ra te in c re a s e , c h ills , a n d m a la is e .
Note: G o u t is m a rk e d b y tr a n s ie n t a tta c k s o f acute arthritis in itia te d b y c r y s ta lliz a tio n
o f u ra te s w ith in a n d a b o u t jo in ts , le a d in g e v e n tu a lly to chronic gouty arthritis a n d th e
a p p e a ra n c e o f tophi. T o p h i r e p re s e n t la rg e a g g r e g a te s o f u ra te c r y s ta ls a n d th e
s u r ro u n d in g in fla m m a to r y r e a c tio n . M o s t, b u t n o t a ll, in d iv id u a ls w ith c h r o n ic g o u t a ls o
d e v e lo p u ra te n e p h ro p a th y .
• Prim ary gout: m o s t c o m m o n fo r m , h y p e r u r ic e m ia w ithout e v id e n t c a u s e :
° m o s t c o m m o n in m id d le - a g e d m e n
° a m a r k e d fa m ilia l p r e d is p o s itio n
• Secondary gout: m u c h le s s c o m m o n . C h a r a c te r iz e d b y h y p e r u r ic e m ia w ith
e v id e n t c a u s e , s u c h as:
° Leukem ia, m ultiple myeloma, a n d m yeloproliferative syndrom es
o Lesch-Nyhan syndrom e: h y p e r u r ic e m ia w ith s e v e r e n e u r o lo g ic m a n ife s ta tio n s
o Pseudogout (c h o n d r o c a lc in o s is ) - c a u s e d b y c a lc iu m p y r o p h o s p h a te d ih y d r a te
c r y s ta l d e p o s itio n , w h ic h e lic its a n in fla m m a to r y re a c tio n in c a rtila g e .
P s e u d o g o u t c lin ic a lly re s e m b le s g o u t.
d is o r d e r s 221

C h o le lith ia s is m a y in d u c e a c u te c h o le c y s titis . E n te r ic b a c te r ia is
c u lt u r e d m o r e c o m m o n ly in c a s e s o f c h r o n ic c h o le c y s titis th a n in
a c u te c h o le c y s tit is .

• b o th s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta t e m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta t e m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y I* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 the first s tatem en t is tru e, the second is false

A cute ch o lecystitis is a su d d e n in fla m m a tio n of th e g a llb la d d e r th a t c a u s e s s e v e re

a b d o m in a l pain. In 90% of cases, a cu te c h o le c y s titis is ca u s e d by g allston es
(c h o le lith ia s is ) in th e g a llb la d d e r. E n te ric b a c te ria c a n be c u ltu re d in 8 0 % o f acute
c h o le c y s titis cases.
A c u te c h o le c y s titis c a u s e s b ile to b e c o m e tra p p e d in th e g a llb la d d e r. T h e b u ild up of bile
c a u s e s irrita tio n and p re s s u re in th e g a llb la d d e r. T h is can lead to b a c te ria l in fe c tio n and
p e rfo ra tio n of th e organ.
C h ro nic c ho lecystitis is th ic k e n in g o f th e g a llb la d d e r w a ll w h ic h o c c u rs as a re s u lt of
e x te n s iv e fib ro s is . It is fre q u e n tly c o m p lic a te d by g a lls to n e s , a nd b a c te ria can be c u ltu re d
in o n ly 3 0 % of cases.
G allsto n es (c h o le lith ia s is ) o c c u r m ore fre q u e n tly in w o m e n th a n m en a n d is often
a s s o c ia te d w ith o b e s ity a n d m u ltip le p re g n a n c ie s . G a lls to n e s b e c o m e m ore c o m m o n w ith
a ge in both s e xe s. Note: N ative A m e ric a n s h ave a h ig h e r ra te of g a llsto n e s.
S tone types:
• C holestero l stones: a re ofte n s o lita ry a nd to o larg e to e n te r th e c y s tic d u c t o r the
c o m m o n b ile duct
• Pigm ent stones:
° P re c ip ita tio n of e x c e s s in so lu b le u n co n ju g a te d b iliru b in re s u lts in th e ir fo rm a tio n .
• A s s o c ia tio n ofte n inc lu d e s h e m o ly tic a n e m ia a nd b a c te ria l infe ctio n .
• M ixed stones: m ost c o m m o n (75% to 80% )
° M ix tu re o f c h o le s te ro l a nd c a lc iu m salts
1. C h o lestero lo sis (s tra w b e rry g a llb la d d e r) is c h a ra c te riz e d by s m a ll, yello w ,
c h o le s te ro l c o n ta in in g fle c k s th a t are h ig h lig h te d a g a in s t a red b a c k g ro u n d in
th e lin in g of th e g a llb la d d e r.
2. D iverticulosis of the g allb lad d er: s m a ll, fin g e r-lik e o u t-p o u c h in g s of th e
g a llb la d d e r lining, m ay d e v e lo p as a p e rso n ages. T h is m a y ca u s e
infla m m a tio n a nd re q u ire g a llb la d d e r rem oval.
3. G a lls to n e s th a t b lo c k th e c o m m o n bile d u c t re s u lt in o b stru ctive jau n d ice
(y e llo w skin c o lo r ca u s e d b y b ile p ig m e n ts b e c o m in g d e p o s ite d in th e skin).
d is o r d e r s 222

W h ic h o f th e fo llo w in g r e s u lt s fr o m in a d e q u a te s e c r e tio n o f th y r o id
h o r m o n e s d u r in g fe ta l life o r e a r ly in fa n c y ?

• m yxedem a
• P lu m m e r d is e a s e
• g ig a n t is m
• c r e tin is m

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • c re tin is m
C r e tin is m is a c o n d itio n o f s tu n te d b o d y g r o w th a n d im p a ir e d m e n ta l d e v e lo p m e n t.
T h e s y m p to m s , w h ic h a p p e a r d u r in g e a r ly in fa n c y , a r e th e g r a d u a l d e v e lo p m e n t o f a
c h a ra c te r is tic c o a r s e , d r y s k in , a s lig h tly s w o lle n fa c e a n d to n g u e , u m b ilic a l h e rn ia ,
a n d a n o p e n m o u th th a t d r o o ls . T h e b a b y is u s u a lly lis tle s s , s lo w - m o v in g ,
c o n s tip a te d , a n d a s lo w fe e d e r . C r e tin is m is th e r e s u lt o f a c o n g e n ita l d e fic ie n c y in
th e s e c re tio n o f th e h o r m o n e th y r o x in e fr o m th e th y r o id g la n d .
In c r e tin is m , th e b a s e o f th e s k u ll is fo r e s h o r te n e d , th e fa c e is w id e a n d s h o r t, th e
m a n d ib le u n d e rd e v e lo p ed , a n d th e m a x illa o v e rd e v e lo p e d . T h e e ru p tio n of
p rim a ry a n d p e rm a n e n t tee th is d e lay e d . T h e lo n g b o n e s m a y b e th ic k e n e d a n d
s h o r t, th e e p ip h y s e s a p p e a r la te a n d a re o fte n ir r e g u la r a n d d e fo r m e d .
M y x e d e m a ( h y p o th y ro id is m in a d u lts ) , o r u n d e r a c tiv ity o f th e th y ro id g la n d , m a y
c a u s e a v a r ie ty o f s y m p to m s a n d m a y a ffe c t a ll b o d y fu n c tio n s . T h e b o d y 's n o rm a l
ra te o f fu n c tio n in g s lo w s , c a u s in g m e n ta l a n d p h y s ic a l s lu g g is h n e s s . T h is c o n d itio n is
c o n s id e r a b ly m o re c o m m o n in w o m e n th a n in m e n . It is c h a r a c te r iz e d b y a
p u ffin e s s o f th e fa c e a n d e y e lid s a n d a s w e llin g o f th e to n g u e a n d la ry n x . T h e s k in
b e c o m e s d r y a n d ro u g h a n d th e h a ir b e c o m e s s p a r s e . T h e a ffe c te d in d iv id u a ls a ls o
h a v e p o o r m u s c le to n e , lo w s tr e n g th , a n d g e t tire d v e r y e a s ily . M e n ta lly th e y a re v e r y
s lu g g is h . T h is c o n d itio n c a n b e a lle v ia te d b y a d m in is te rin g th y r o id h o r m o n e s . R is k
fa c to rs in c lu d e a g e o v e r 5 0 y e a r s , fe m a le g e n d e r, o b e s ity , th y r o id s u r g e r y , a n d
e x p o s u r e o f th e n e c k to x - r a y o r r a d ia tio n tr e a tm e n ts .
^ 1. T h e s e c re tio n o f T 3 ( tr iio d o th y ro n in e ) a n d T 4 ( th y r o x in e ) is c o n tr o lle d b y
th e p itu ita r y g la n d a n d th e h y p o th a la m u s , w h ic h is p a r t o f th e b ra in .
2. T h y ro id d is o rd e r s m a y r e s u lt n o t o n ly fro m d e fe c ts in th e th y ro id g la n d
its e lf, b u t a ls o fr o m a b n o r m a litie s o f th e p itu ita r y o r h y p o th a la m u s .
3. T h e m a jo r ity o f th e m e ta b o lic a lly a c tiv e T 3 is fo r m e d in th e p e r ip h e r a l
tis s u e s b y c o n v e r s io n o f s e c r e te d T 4 .
d is o rd e rs 223

W h ic h o f th e fo llo w in g is a s s o c ia te d w ith e s o p h a g e a l v a ric e s ?

• h e m o p ty s is
• h e m a tu r ia

• h e m o p h ilia
• h e m a te m e s is

M IC R O B IO L O G Y /P A T H O L O G Y Q j^ d e n t a ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • h e m a t e m e s is
B lo o d in th e u r in e s h o u ld n e v e r b e ig n o re d ! B lo o d in th e u r in e is u s u a lly
c a u s e d b y k id n e y a n d u r in a r y t r a c t d is e a s e s . H o w e v e r , th e r e a r e a c o u p le o f
e x c e p tio n s :
• In w o m e n , th e b lo o d m a y a p p e a r to b e in th e u r in e w h e n it's a c t u a lly
c o m in g fr o m th e v a g in a .
• In m e n , th e u r e th r a c a r r ie s b o th u r in e a n d s e m e n o u t o f th e b o d y a n d w h a t
m a y b e m is ta k e n f o r u r in a r y b le e d in g is s o m e t im e s a b lo o d y e ja c u la tio n
u s u a lly d u e t o a p r o s t a t e p r o b le m .
• In c h ild r e n , c o a g u la t io n d is o r d e r s ( s u c h a s h e m o p h ilia ) o r o t h e r
h e m a t o lo g ic p r o b le m s s u c h a s s ic k le c e ll d is e a s e , r e n a l v e in t h r o m b o s is , o r
th e th r o m b o c y t o p e n ia s c a n b e u n d e r ly in g r e a s o n s f o r n e w ly d is c o v e r e d
b lo o d in t h e u r in e . N o te : K id n e y d is e a s e fo llo w in g s tr e p , t h r o a t is a c la s s ic
c a u s e o f b lo o d in t h e u r in e in c h ild r e n .
„ 1. H e m a t e m e s is is th e v o m it in g o f b r ig h t r e d b lo o d , in d ic a t in g r a p id
u p p e r G l b le e d in g . It is c o m m o n ly a s s o c ia t e d w it h e s o p h a g e a l
v a r ic e s ( c o m m o n in a lc o h o lic s ) o r p e p t ic u lc e r s .
2 . H e m o p ty s is is th e c o u g h in g u p o f b lo o d fr o m th e r e s p ir a t o r y tr a c t.
B lo o d - s t r e a k e d s p u tu m o ft e n o c c u r s in m in o r u p p e r r e s p ir a t o r y
in f e c t io n s o r in b r o n c h it is . P a tie n ts s u f f e r in g f r o m t u b e r c u lo s is ,
p n e u m o n ia , o r b r o n c h o g e n ic c a r c in o m a m a y a ls o e x p e r ie n c e
h e m o p t y s is . T h e m a in s y m p t o m o f id io p a t h ic p u lm o n a r y
h e m o s id e r o s is ( ir o n in th e lu n g s ) is h e m o p t y s is .
3 . G lu c o s u r ia is th e p r e s e n c e o f g lu c o s e ( s u g a r ) in th e u r in e ;
c o m m o n in d ia b e tic s .
4. K e to n u r ia is th e p r e s e n c e o f k e t o n e s in th e u r in e ; p r o d u c e d b y
s ta r v a tio n , u n c o n tr o lle d d ia b e te s , a n d o c c a s io n a lly a lc o h o l
in to x ic a tio n .
5 . P r o te in u r ia is th e p r e s e n c e o f p r o te in in th e u r in e ; u s u a lly a s ig n o f
k id n e y d is e a s e .
d is o r d e r s 224

W h ic h v e s s e ls a r e p a r tic u la r ly p ro n e to te a r in g a lo n g th e ir c o u r s e
th r o u g h th e s u b d u r a l s p a c e a n d a r e th e s o u r c e o f b le e d in g in m o s t
c a s e s o f s u b d u r a l h e m a to m a ?

• t h e m id d le m e n in g e a l a r te r y
• th e m id d le c e r e b r a l a r t e r ie s
• a b e r r y a n e u r y s m in th e c ir c le o f W illis
• t h e b r id g in g v e in s

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • the b rid g in g veins
V a s c u la r in ju ry is a fre q u e n t c o m p o n e n t o f C N S tra u m a . It re s u lts fro m d ire c t tra u m a and
d is ru p tio n o f th e v e s s e l w a ll and le a d s to h e m o rrh a g e . D e p e n d in g on th e a n a to m ic
p o s itio n of th e ru p tu re d v e s s e l, h e m o rrh a g e m a y o c c u r in th e e p id u ra l, s u b d u ra l,
s u b a ra c h n o id , an d in tra p a re n c h y m a l c o m p a rtm e n ts , s o m e tim e s in c o m b in a tio n .
A n e pidu ral hem atom a (ED H ) is an a rte ria l h e m o rrh a g e b e tw e e n th e d u ra an d th e skull,
m o st o fte n re s u ltin g fro m s k u ll fra c tu re s a n d la c e ra tio n of th e m idd le m en in geal artery.
EDH is c h a ra c te riz e d c lin ic a lly by a s h o rt p e rio d of c o n s c io u s n e s s (lucid in te rva l) fo llo w e d
by loss of c o n s c io u s n e s s a n d s ig n s o f c e re b ra l c o m p re s s io n . A n e p id u ra l h e m a to m a m ay
e x p a n d ra p id ly a n d is a n e u ro s u rg ic a l e m e rg e n c y re q u irin g p ro m p t d ra in a g e .
S u b d u ral h em atom as (S D H ) o c c u r b e tw e e n th e in n e r s u rfa c e of th e d u ra m a te r an d the
o u te r a ra c h n o id layer. B rid g in g veins tra ve l fro m th e c o n v e x itie s o f th e ce re b ra l
h e m is p h e re s th ro u g h th e s u b a ra c h n o id s p a c e an d th e s u b d u ra l s p a c e to e m p ty into the
s u p e rio r s a g itta l sin u s. S im ila r a n a to m ic re la tio n s h ip s e x is t w ith o th e r d u ra l s in u s e s . T h e s e
v e s s e ls a re p a rtic u la rly p ro n e to te a rin g a lo n g th e ir c o u rs e th ro u g h th e s u b d u ra l sp a ce
an d a re th e s o u rc e of b le e d in g in m o s t c a s e s o f s u b d u ra l h e m a to m a .
P a tie n ts w ith S D H c o m m o n ly p re s e n t a fte r a c u te d e c e le ra tio n in ju ry from a fa ll o r m o to r
v e h ic le a c c id e n t, but a re ra re ly a s s o c ia te d w ith s k u ll fra c tu re . M o s t o fte n m a n ife s t w ith in
48 hou rs of in ju ry. C lin ic a l m a n ife s ta tio n s in c lu d e h e a d a c h e and c o n fu s io n .
S u barach n o id h em o rrh ag e is c o m m o n ly a s s o c ia te d w ith ru p tu re of a berry an eu rysm in
th e circle o f W illis. T h e ru p tu re is m o s t lik e ly to o c c u r in y o u n g to m id d le a ge adu lts.
1. A tra n s ie n t is c h e m ic a tta c k is a b rie f e p is o d e o f im p a ire d n e u ro lo g ic fu n c tio n
c a u s e d by a b rie f d is tu rb a n c e in c e re b ra l circ u la tio n .
2. A b rain c on c uss io n is th e im m e d ia te an d te m p o ra ry d is tu rb a n c e o f brain
fu n c tio n as m a n ife s te d by d iz z in e s s , c o ld p e rs p ira tio n , v is u a l d is tu rb a n c e s ,
a nd loss of c o n s c io u s n e s s . M o s t p e o p le re c o v e r c o m p le te ly w ith in a fe w
h o u rs o r d ays. O n e c o m p lic a tio n is p o stco n cu ssio n syndrom e.
3. A m en in g iom a is an in tra c ra n ia l tu m o r a ris in g fro m a ra c h n o id , u su a lly
o c c u rrin g in a d u lts o v e r 30 y e a rs o f age.
d is o r d e r s 225

W h ic h o f th e fo llo w in g is a c lin ic a l m a n if e s ta tio n o f a d e fic ie n c y o f

v ita m in A ?

• r ic k e t s
• n e u r o lo g ic a l d is o r d e r s
• c o a g u la tio n d e fe c t s
• n ig h t b lin d n e s s

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 n ig h t b lin d n e s s

S u m m a ry o f F a t- S o lu b le V ita m in s

Vitamin Physiological functions M ajor clinical features o f deficiency

A H elps m aintain norm al body growth and X erophthalm ia, night blindness, keratom alacia,
(retinol) health o f specialized tissues, especially follicular hyperkeratosis
retina. Production o f rhodopsin
(photopigm ent)

D Essential in formation o f bone R ickets in children, osteom alacia in adults

(cholecalciferol)

E A ntioxidant N eurological disorders, e.g. ataxia

(a-tocopherol)

K Involved in clotting o f blood Coagulation defects

d is o r d e r s 226

P a th o lo g ic c a lc if ic a tio n is th e a b n o r m a l tis s u e d e p o s it io n o f c a lc iu m
s la ts , to g e th e r w ith s m a lle r a m o u n ts o f iro n , m a g n e s iu m , a n d o th e r
m in e r a l s a lts .
T h e r e a r e tw o fo r m s o f p a th o lo g ic c a lc if ic a tio n : d y s tr o p h ic a n d
m e ta s ta tic .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• t h e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • both statem ents are true
P athologic calcification is the abnorm al tissue deposition of calcium salts, together with
sm aller am ounts of iron, m agnesium , and other mineral salts. W hen deposition occurs locally in
dying tissues it is known as dystrophic calcification; it occurs despite normal serum levels of
calcium and in the absence of derangem ents in calcium metabolism . In contrast, the deposition
of calcium salts in otherw ise norm al tissues is known as m etastatic calcification, and it alm ost
always results from hypercalcem ia secondary to som e disturbance in calcium metabolism.
There are two form s of pathologic calcification:
1. D ystrophic calcification is encountered in area of necrosis, w hether they are coagulative,
caseous, or liquefactive type, and in foci of enzym atic necrosis of fat. It com m only develops
in aging or dam aged heart valves, atherom as of advanced atherosclerosis and tuberculosis
lesions.
2. M etastatic calcification m ay occur in normal tissues w henever there is hypercalcem ia. It
may occur widely throughout the body but principally affects the interstitial tissues of the
gastric m ucosa, kidneys, lungs, system ic arteries, and pulm onary veins.
There are fo u r principal causes of hypercalcem ia: (1) increased secretion of parathyroid
horm one with subsequent bone resorption, as in hyperparathyroidism ; (2) destruction of bone
tissue, secondary to primary tum ors of bone m arrow (e.g., m ultiple m yeloma, leukem ia); (3)
vitam in D-related disorders; and (4) renal failure, which causes retention of phosphate, leading to
secondary hyperparathyroidism .
1. A s ialolith is a stone (salivary calculus) within a salivary gland o r duct. The
form ation o f a sialolith is called s ialolith iasis and o ccurs as a result of
precipitation o f calcium and phosphate salts around a nidus of m ucous or bacterial
debris. Sialoliths occur as single or m ultiple stones and can cause swelling and
pain. The pain is experienced during salivary stim ulation and is intensified at
m ealtimes. M ost stones are found in the subm andibular duct (W harton's) and gland
than in the parotid duct (Stensen's) and gland.
2. Kidney stones are calculi occurring in the kidney. Calculi too large to pass
spontaneously range in size from 1 cm to the staghorn stones that occupy the renal
pelvis and calyces. Bilateral renal calculi cause additional problems, with infection a
com m on occurrence.
3. C alcin o sis is calcification that occurs in o r under the skin. Scleroderm a,
derm atom yositis, and m ultiple m iliary osteom as are exam ples o f calcinosis.
d is o r d e r s 227

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith

v ita m in B 6.

• com ponent of NAD and NA D P

• com ponent of FAD and FM N
• w e t b e r ib e r i
• c h e ilo s is
• p e lla g r a
• r e q u ir e d fo r p o r p h y r in s y n th e s is
• r e q u ir e d fo r th e h y d r o x y la t io n o f p r o lin e a n d ly s in e
• a n e m ia

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • c h e ilo s is
• r e q u ir e d fo r p o r p h y r in s y n th e s is
• a n e m ia
S u m m a r y o f W a te r S o lu b le V itn in in s

V it a m in P h y s io lo g ic a l fu n c tio n s R e s u l ts o f D e ficie n c y

B| C o c n z y m e th ia m in e p y r o p h o s p h a te W e t b e rib e ri, d ry b e rib e ri, W e m ic k e - K o r s a k o f f s y n d ro m e

(th ia m in e ) p la y s a k e y ro le in c a rb o h y d ra te a n d
a m in o a c id in te rm e d ia ry m e ta b o lis m

B, C o m p o n e n t o f F A D a n d F M N a n d is C h e ilo s is , g lo s s itis , d e rm a titis

(rib o f la v in ) e s s e n tia l in a v a rie ty o f o x id a tio n -

re d u c tio n p r o c e s s e s

B, C om ponent o f N A D and N A D P. P e lla g ra

(n ia c in ) e s s e n t ia l to g ly c o ly s is , th e c itr ic a c id
c y c le , a n d to a v a rie ty o f o x id a tio n
re a c tio n s

B* R e q u ir e d f o r tr a n s a m in a tio n , p o r p h y r i u C h e ilo s is , g lo s s itis , a n e m ia

(p y r id o x in o ) s y n th e s is , s y n th e s is o f n ia c in fro m
try p to p h a n

Bu 1- c a r b o n t r a n s f e r s r e q u i r e d f o r f o l a t e M e g a lo b la s tic a n e m ia , n e u ro lo g ic d y s fu n c tio n

(c o b a la m in ) s y n th e s is a n d a c tiv a tio n o f F H i

F o lic a c id 1- c a r b o n t r a n s f e r s in a n u m b e r o f M e g a lo b la s tic a n e m ia ; • • • N e u r o lo g ic d y s fu n c tio n is n o t

m e ta b o lic r e a c tio n s a f e a tu r e ( a s it is in v ita m in B u d e fic ie n c y )

C R e q u ire d fo r th e h y d ro x y la tio n o f S c u r v y , d e fe c tiv e w o u n d h e a lin g

(a s c o r b i c a c i d ) p m li n c a n d ly s in e , w h ic h a rc e s s e n tia l
fo r c o lla g e n s y n th e s is ; h y d ro x y la tio n o f
d o p a m in e in th e s y n th e s is o f
n o re p in e p h rin e
d is o r d e r s 228

T r a c h o m a is a n e y e in fe c tio n c a u s e d b y w h ic h o f t h e fo llo w in g ?

• c h la m y d ia tr a c h o m a tis
• b a c t e r o id e s fr a g ilis
• p r e v o te lla in t e r m e d ia
• le p to s p ir a in te r r o g a n s

M IC R O B IO L O G Y /P A T H O L O G Y I^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • c h la m y d ia tra c h o m a tis
C o n ju n c tiv itis is o n e o f th e m o s t c o m m o n a n d tr e a ta b le e y e in fe c tio n s in c h ild r e n a n d
a d u lts . O fte n c a lle d "pink eye," it is a n in fla m m a tio n o f th e c o n ju n c tiv a , th e tis s u e th a t
lin e s th e in s id e o f th e e y e lid .
C o n ju n c tiv itis c a n b e c a u s e d b y a v iru s , b a c te r ia , irr ita tin g s u b s ta n c e s ( s h a m p o o s ,
d irt, s m o k e , a n d e s p e c ia lly p o o l c h lo r in e ) , a lle r g e n s o r s e x u a lly tr a n s m itte d d is e a s e s
(S T D s ) . P in k e y e c a u s e d b y b a c te r ia , v iru s e s , a n d S T D s c a n s p r e a d e a s ily fr o m
p e r s o n to p e r s o n .
C o m m o n fe a tu r e s in a ll ty p e s o f c o n ju n c tiv itis in c lu d e s o r e n e s s , re d n e s s a n d
d is c h a r g e , a n d in g e n e r a l th e v is u a l a c u ity is g o o d . N o te: In th e n e o n a te it is v ita l to
e n s u r e th e r e h a s b e e n n o a s s o c ia te d m a te r n a l s e x u a lly tr a n s m itte d in fe c tio n .
1 . T ra c h o m a is a n e y e in fe c tio n c a u s e d b y C h la m y d ia tr a c h o m a tis . It is th e
m o s t c o m m o n c a u s e o f p re v e n ta b le b lin d n e s s in u n d e r d e v e lo p e d a r e a s
o f th e w o r ld .
2. R e tin o p a th y o f p re m a tu rity ( re tr o le n ta l fib ro p la s ia ) is d u e to to x ic ity of
th e r a p e u tic o x y g e n , m o s t o fte n a d m in is te r e d b e c a u s e o f n e o n a ta l
r e s p ir a to r y d is tr e s s s y n d ro m e (h y a lin e m e m b r a n e d is e a s e ) . It le a d s to
b lin d n e s s .
3. D ia b e tic re tin o p a th y is a m a jo r c a u s e o f b lin d n e s s .
4. R etin itis p ig m e n to s a is c h a ra c te r iz e d b y h e r e d ita r y n ig h t b lin d n e s s
w ith p ro g r e s s iv e lo s s o f c e n tr a l v is io n . It is c a u s e d b y e a r ly lo s s o f ro d s
a n d la te r lo s s o f c o n e s .
5. M ac u la r d e g e n e ra tio n of th e a g ed ( s e n ile m a c u la r d e g e n e r a tio n ) is a
m a jo r c a u s e o f im p a ire d v is io n in th e e ld e r ly . It is o fte n b ila te r a l.
6. G la u c o m a - tw o fo rm s :
o O p e n -a n g le : m o s t c o m m o n fo r m ; c h a r a c te riz e d b y g r a d u a lly
in c r e a s in g o c u la r p r e s s u r e , le a d in g to v is u a l im p a ir m e n t a n d ,
e v e n tu a lly b lin d n e s s .
» A n g le -c lo s u re : c a u s e d b y n a r r o w a n te r io r c h a m b e r a n g le ; in c r e a s e
in in tr a o c u la r p r e s s u r e o n d ila tio n o f p u p il.
7. R e tin o b la s to m a is a m a lig n a n t re tin a l tu m o r o f c h ild h o o d .
d is o r d e r s 229

A p a tie n t g o e s to th e e m e r g e n c y ro o m w ith s e v e r e m id -a b d o m in a l
p a in . T h e p h y s ic ia n s u s p e c ts a c u te p a n c r e a tit is a n d o r d e r s a b lo o d
te s t. L a b v a lu e s s h o w e le v a te d s e r u m lip a s e . T o c o n fir m th e
d ia g n o s is , w h a t o th e r e n z y m e w o u ld lik e ly b e e le v a te d ?

• a lk a lin e p h o s p h a ta s e
• a m y la s e
• g lu c o s e - 6 - p h o s p h a ta s e
• a c id p h o s p h a ta s e

M IC R O B IO L O G Y /P A T H O L O G Y ® M en tald ecl<S
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • a m y la s e
P a n c r e a titis is a n in fla m m a tio n o r in fe c tio n o f t h e p a n c r e a s . T h e p a n c r e a s is
a n e lo n g a te d , ta p e r e d g la n d t h a t is lo c a te d b e h in d th e s to m a c h . It s e c r e te s
d ig e s t iv e e n z y m e s a n d th e h o r m o n e s in s u lin a n d g lu c a g o n . P a n c r e a t it is is
o f te n c a u s e d b y t h e d ig e s t io n o f p a r ts o f t h e o r g a n b y p a n c r e a t ic e n z y m e s t h a t
a r e n o r m a lly c a r r ie d t o th e s m a ll in te s tin e w ith in t h e p a n c r e a t ic d u c ts .
In a c u te p a n c r e a titis , w h ic h is c a u s e d b y o b s t r u c t io n o f t h e n o r m a l p a t h w a y o f
s e c r e tio n o f p a n c r e a tic ju ic e in to t h e in te s tin e , th e z y m o g e n s o f t h e p r o te o ly tic
e n z y m e s a r e c o n v e r te d in to th e ir c a t a ly t ic a lly a c tiv e f o r m s p r e m a tu r e ly , in s id e
th e p a n c r e a tic c e lls . A s a r e s u lt, th e s e p o w e r fu l e n z y m e s a t t a c k th e
p a n c r e a t ic t is s u e its e lf, c a u s in g a p a in fu l a n d s e r io u s d e s t r u c t io n o f t h e o r g a n ,
w h ic h c a n b e fa ta l. It is a s s o c ia t e d w it h a lc o h o lis m a n d b ilia r y d is e a s e .
N o te : M a n if e s t a t io n s o r c o n s e q u e n c e s o f a c u t e p a n c r e a t it is in c lu d e e n z y m a t ic
h e m o r r h a g ic f a t n e c r o s is w it h c a lc iu m soap fo r m a t io n and r e s u lta n t
h y p o c a lc e m ia .
Im p o r ta n t: T h e c a r d in a l c lin ic a l s ig n is s e v e r e m id -a b d o m in a l p a in . T h is
d iffe r s fr o m a c u te c h o le c y s titis w h ic h f e a t u r e s s e v e r e R U Q o r u p p e r
a b d o m in a l p a in ; it a ls o d if fe r s fr o m a c u te a p p e n d ic itis w h ic h fe a tu r e s
s e v e r e R L Q a b d o m in a l p a in w ith m a r k e d r e b o u n d p a in to p a lp a tio n .
d is o r d e r s 230

N e u r o fib r o m a to s is T y p e 1 is c h a r a c te r iz e d b y a ll o f th e fo llo w in g
E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• m u lt ip le s k in n e u r o fib r o m a s
• g lio m a s o f th e o p tic n e rv e
• m u ltip le m e n in g io m a s
• p ig m e n te d n o d u le s o f th e ir is
• c u t a n e o u s h y p e r p ig m e n te d m a c u le s

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • m u ltip le m e n in g io m a s
N e u ro fib ro m a to s is ty p e 1 (a k a , v o n R e c k lin g h a u s e n 's d is e a s e ) is a n a u to s o m a l
d o m in a n t d is o r d e r a n d o n e o f th e m o r e c o m m o n g e n e tic d is o r d e r s , h a v in g a
fr e q u e n c y o f 1 in 3 0 0 0 . It is c h a r a c te r iz e d b y n e u ro fib ro m a s ( p le x ifo r m a n d s o lita r y ) ,
g lio m a s o f th e o p tic n e rv e , p ig m e n te d n o d u le s o f th e iris ( L is c h n o d u le s ), a n d
c u ta n e o u s h y p e rp ig m e n te d m a c u le s ( c a fe -a u - la it s p o ts ) . N o te: T h e re is a
p ro p e n s ity fo r th e n e u r o fib r o m a s , p a r tic u la r ly p le x ifo r m n e u r o fib r o m a s , to u n d e r g o
m a lig n a n t d e g e n e r a tio n a t a h ig h e r r a te th a n th a t o b s e r v e d fo r c o m p a r a b le tu m o r s
in th e g e n e r a l p o p u la tio n .
T h e c o u r s e o f th e d is e a s e is h ig h ly v a r ia b le ; s o m e in d iv id u a ls w h o c a r r y a m u ta te d
g e n e h a v e n o s y m p to m s , w h ile o th e r s d e v e lo p p ro g r e s s iv e d is e a s e w ith s p in a l
d e fo r m itie s , d is fig u rin g le s io n s , a n d c o m p re s s io n o f v ita l s tr u c tu r e s , in c lu d in g th e
s p in a l c o r d .
N e u ro fib ro m a to s is ty p e 2 is a ls o a n a u to s o m a l d o m in a n t d is o r d e r r e s u ltin g in a
ra n g e o f tu m o r s , m o s t c o m m o n ly b ila teral e ig h th -n e rv e s c h w a n n o m a s a n d
m u ltip le m e n in g io m a s . G lio m a s , ty p ic a lly e p e n d y m o m a s o f th e s p in a l c o r d , a ls o
o c c u r in th e s e p a tie n ts . It is m u c h le s s c o m m o n th a n N F -1 . N o te: R a re ly, th e b e n ig n
tu m o r s u n d e r g o s a r c o m a to u s c h a n g e .
O th e r a u to s o m a l d o m in a n t d is o r d e r s :
• F am ilial h y p e rc h o le s te ro le m ia : c h a ra c te r iz e d b y a n o m a lie s o f r e c e p to r s fo r
lo w -d e n s ity lip o p r o te in s
• H e re d ita ry h e m o rrh a g ic te la n g ie c ta s ia (O s le r-W e b e r-R e n d u s y n d ro m e ):
c h a ra c te r iz e d b y lo c a l te la n g ie c ta s e s o f th e s k in a n d m u c o u s m e m b ra n e s a n d b y
r e c u r re n t h e m o r r h a g e fr o m th e s e le s io n s . C o m m o n in M o r m o n fa m ilie s o f U ta h .
• M a rfan s y n d ro m e: c h a ra c te r iz e d b y d e fe c ts in s k e le ta l, v is u a l, a n d
c a r d io v a s c u la r s tr u c tu r e s . P a tie n ts a re ta ll a n d th in w ith a b n o r m a lly lo n g le g s a n d
a rm s , s p id e r - lik e fin g e r s ( a r a c h n o d a c ty ly ) , a n d h y p e re x te n s ib le jo in ts . H e a rt
p r o b le m s in c lu d e : a n e u r y s m o f th e p r o x im a l a o r ta , m itra l v a lv e p r o la p s e a n d
d is s e c tin g a n e u r y s m o f th e a o rta .
• A d u lt p o ly c y s tic k id n e y d is e a s e : is c h a ra c te r iz e d b y n u m e ro u s b ila te r a l c y s ts
th a t r e p la c e a n d d e s tr o y th e re n a l p a r e n c h y m a .
d is o r d e r s 231

T h e m o s t c o m m o n c a u s e o f h y p o th y r o id is m in a d u lts is
G ra v e s ' d is e a s e .
H y p o th y r o id is m c a n b e c a u s e d b y a n io d in e d e fic ie n c y .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• t h e fir s t s ta t e m e n t is tr u e , th e s e c o n d is f a ls e
• th e fir s t s ta t e m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y i t d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • the first sta te m e nt is false, the seco n d is true
T h e m ost c o m m o n c a u s e o f h yp o th yro id ism in a d u lts is H a s h im o to 's th y ro id itis (also
c a lle d c h ro n ic th y ro id itis o r H a s h im o to 's d ise a se ). It is a c o m m o n th y ro id g la n d d iso rd e r
th a t ca n o c c u r a t a n y age, b u t m o st o fte n o cc u rs in m id d le -a g e d w o m e n . It h as on e o f th e
s tro n g e s t fe m a le p re d ile c tio n s o f a n y d is e a s e kn ow n to m an. It is c a u s e d by a re a c tio n of
th e im m u n e s y s te m a g a in s t th e th y ro id g la n d .
C linical ch aracteristics in c lu d e :
• T h e o n s e t o f th e d is e a s e is slow , an d it m ay ta ke m o n th s o r eve n y e a rs fo r the
c o n d itio n to be d e te c te d
• T h e s y m p to m s of h yp o th yro idism a re e v id e n t (fa tig u e , s lo w e d s p e e c h , cold
in to le ra n c e , d ry skin, c o a rs e hair, p u ffy fa ce , etc.)
• T h o u g h th e th y ro id m ay in itia lly ha ve been p a in le s s ly e n la rg e d , o v e r tim e the
in fla m m a tio n leads to a tro p h y of th e th y ro id w ith h y p o th y ro id is m
1. H a s h im o to 's th y ro id itis is a s s o c ia te d w ith v a rio u s au to an tibo d ies , m o st
n o ta b ly a n tith y ro g lo b u lin , a n tith y ro id p e ro x id a s e , a n ti-T S H re c e p to r, a n d a n ti­
io d in e re c e p to r a n tib o d ie s .
2. H is to lo g ic c h a ra c te ris tic s in c lu d e m assive infiltrates of lym p h ocytes w ith
g e rm in a l c e n te r fo rm a tio n .
3. A utoim m u n e d isease re fe rs to a d ise a s e re s u ltin g fro m an im m un e reaction
p ro d u c e d b y an in d iv id u a l's w h ite b lo o d c e lls o r a n tib o d ie s a c tin g on th e
b o d y 's ow n tis s u e s . In th e c a s e o f H a s h im o to 's d is e a s e , th e re is th e
p ro d u ctio n of a n tib o d ies in re s p o n s e to th y ro id a n tig e n s an d the
re p la c e m e n t of no rm a l th y ro id s tru c tu re s w ith ly m p h o c y te s an d lym p h o id
g e rm in a l c e n te rs .
4. P rim a ry h yp e rp a ra th y ro id is m is m o st o fte n c a u s e d by a p arathyro id
adenom a.
5. H y p o th y ro id is m (cre tin ism an d m y x e d e m a ) ca n be c a u s e d by an io d in e
deficiency.
6. G raves' d isease is th e m o st c o m m o n c a u s e o f e n d o g e n o u s
h yp erthyro id ism . W o m e n a re a ffe c te d as m uch as 10 tim e s m ore fre q u e n tly
th a n m en. It is c h a ra c te riz e d by a b re a k d o w n in s e lf-to le ra n c e to th y ro id a u to ­
a n tig e n s , m o s t im p o rta n tly th e T S H re c e p to r. T h e re s u lt is th e p ro d u c tio n of
m u ltip le a u to a n tib o d ie s .
d is o r d e r s 232

A s o m a to tr o p ic a d e n o m a w ith h y p e r s e c r e tio n o f g r o w th h o r m o n e
th a t d e v e lo p s b e fo r e e p ip h y s e a l c lo s u r e r e s u lts in:

• c r e tin is m
• a c r o m e g a ly

• g ig a n tis m
• m yxedem a

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • g ig a n tis m
A n te rio r p itu ita r y h y p e rfu n c tio n is u s u a lly d u e to b e n ig n s lo w g ro w in g tu m o r s .
• P ro la c tin o m a w ith h y p e r p r o la c tin e m ia :
° M o s t c o m m o n p itu ita r y tu m o r (3 0 % )
» In w o m e n it r e s u lts in a m e n o r r h e a a n d g a la c to rr h e a ( in a p p r o p ria te m ilk
s e c r e tio n )
• S o m a to tro p ic a d e n o m a w ith h y p e r s e c r e tio n o f g ro w th h o rm o n e:
° S e c o n d m o s t c o m m o n p itu ita r y tu m o r
° G ig a n tis m r e s u lts if a d e n o m a d e v e lo p s b efo re e p ip h y s e a l c lo s u r e
° A c ro m e g a ly r e s u lts if a d e n o m a d e v e lo p s a fte r e p ip h y s e a l c lo s u r e
C o m m o n fin d in g s in c lu d e :
■ G r a d u a l m a r k e d e n la r g e m e n t o f th e h e a d , fa c e , h a n d s , fe e t, a n d c h e s t
■ E x c e s s iv e p e r s p ir a tio n a n d a n o ffe n s iv e b o d y o d o r
■ P r o g n a th is m ( m a n d ib le p r o tr u d e s )
■ E n la r g e d to n g u e
■ D e e p v o ic e
• C o rtic o tro p ic a d e n o m a w ith h y p e r s e c r e tio n o f A C T H :
° H y p e rc o r tic a lis m (C u s h in g s y n d ro m e ): th is d is o r d e r is c a u s e d b y a n y
c o n d itio n th a t p r o d u c e s e le v a te d g lu c o c o r tic o id le v e ls . It c a n b e b r o a d ly
d iv id e d in to e x o g e n o u s a n d e n d o g e n o u s c a u s e s . T h e v a s t m a jo r ity o f c a s e s o f
C u s h in g s y n d r o m e a r e th e r e s u lt o f th e a d m in is tr a tio n o f e x o g e n o u s
g lu c o c o r tic o id s . T h e e n d o g e n o u s c a u s e s c a n , in tu r n , b e d iv id e d in to th o s e
th a t a r e A C T H d e p e n d e n t a n d th o s e th a t a r e A C T H in d e p e n d e n t.
1. D e fic ie n c y of g ro w th h o rm o n e :
» In c h ild re n , th is r e s u lts in p itu ita r y d w a rfis m
« In a d u lts , th is m a y r e s u lt in in c r e a s e d in s u lin s e n s itiv ity w ith
h y p o g ly c e m ia , d e c re a s e d m u s c le s tre n g th , a n d a n e m ia
2. D e fic ie n c y of g o n a d o tro p in s : In p r e a d o le s c e n t c h ild r e n , th is r e s u lts in
re ta r d e d s e x u a l m a tu r a tio n . In a d u lts , th is r e s u lts in lo s s o f lib id o ,
im p o te n c e , lo s s o f m u s c u la r m a s s , a n d d e c r e a s e d fa c ia l h a ir in m e n , a n d
a m e n o r r h e a in w o m e n .
d is o r d e r s 233

T h e p a th o g n o m o n ic le s io n o f e r y th e m a m u ltifo r m e is a:

• b u tt e r fly r a s h
• " ta r g e t" le s io n
• " p a s te d - o n " p la q u e
• H ill- S a c h s le s io n

M IC R O B IO L O G Y /P A T H O L O G Y i * d e n ta ld e c k s
P a ri I • V o lu m e 1 3 • © 2 0 1 7
 • “t a r g e t ” le s io n
E r y th e m a m u lt if o r m e ( E M ) is a n u n c o m m o n , s e lf - lim it e d d is o r d e r t h a t s e e m s
to b e a h y p e r s e n s it iv it y r e a c tio n to c e r ta in in f e c t io n s a n d d r u g s . T h is d is o r d e r
a ff e c ts in d iv id u a ls o f a n y a g e a n d is a s s o c ia t e d w it h th e f o llo w in g c o n d it io n s :
• In f e c t io n s s u c h a s h e r p e s s im p le x , m y c o p la s m a l in fe c tio n s , h is to p la s m o s is ,
c o c c id io id o m y c o s is , ty p h o id , a n d le p r o s y , a m o n g o th e r s
• A d m in is t r a t io n o f c e r t a in d r u g s ( s u lfo n a m id e s , p e n ic illin , b a r b itu r a te s ,
s a lic y la te s , h y d a n to in s , a n d a n tim a la r ia ls )
• M a lig n a n t d is e a s e ( c a r c in o m a s a n d ly m p h o m a s )
• C o lla g e n v a s c u la r d is e a s e s ( lu p u s e r y th e m a to s u s , d e r m a t o m y o s it is , a n d
p o ly a r te r itis n o d o s a )
A f f e c t e d in d iv id u a ls p r e s e n t w it h a n a r r a y o f “ m u lt if o r m ” le s io n s , in c lu d in g
m a c u le s , p a p u le s , v e s ic le s , a n d b u lla e a s w e ll a s th e c h a r a c t e r is t ic “ t a r g e t ”
le s io n c o n s is t in g o f a r e d m a c u le o r p a p u le w it h a p a le , v e s ic u la r , o r e r o d e d
c e n te r . A lt h o u g h le s io n s m a y b e w id e ly d is tr ib u te d , s y m m e t r ic in v o lv e m e n t o f
t h e e x tr e m itie s f r e q u e n t ly o c c u r s .
• A n e x t e n s iv e a n d s y m p t o m a t ic fe b r ile fo r m o f th e d is e a s e , w h ic h is o ft e n
but n o t e x c lu s iv e ly seen in c h ild r e n , is c a lle d S te v e n s -J o h n s o n
s y n d ro m e .
• A n o t h e r v a r ia n t, t e r m e d to x ic e p id e r m a l n e c r o ly s is , r e s u lts in d iff u s e
n e c r o s is a n d s lo u g h in g o f c u t a n e o u s a n d m u c o s a l e p ith e lia l s u r fa c e s ,
p r o d u c in g a c lin ic a l s itu a tio n a n a lo g o u s t o a n e x t e n s iv e b u r n w h e n b o t h
in fe c tio n a n d flu id lo s s a r e c lin ic a l c o n c e r n s .
Im p o r ta n t: T h e c la s s ic le s io n is c h a r a c t e r iz e b y a c e n tr a l le s io n s u r r o u n d e d b y
c o n c e n t r ic r in g s o f p a llo r a n d r e d n e s s , t h is is c o m m o n ly r e fe r r e d to as a
“t a r g e t ,” “ ir is ,” o r “ b u ll's e y e ” s h a p e d le s io n .
d is o r d e r s 234

F o r e a c h n u m b e r e d s y m p to m lis te d b e lo w , s e le c t th e m o s t c lo s e ly
lin k e d d is o r d e r fr o m th e lis t p ro v id e d .

1. V e s ic le s o n m u c o s a A . P e m p h ig u s
2 . L a r g e , re d n o s e B . V it ilig o
3. H o n e y c o lo r e d c r u s t, s u p e r fic ia l C . X a n th o m a
s k in in fe c tio n D. R o s a ce a
4 . H e r a ld p a tc h
E . I m p e tig o
5 . Ir r e g u la r p ig m e n ta tio n F . P it y r ia s is
6. G . C a p illa r y h e m a n g io m a
7.

M IC R O B IO L O G Y /P A T H O L O G Y H f r d e n t a ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 1.A , 2.D , 3.E, 4.F, 5.B
S k i n D is c u s e s o r C o n d i t i o n s

K ey fe a tu re s

P e m p h ig u s • V e s ic le s o n m u c o s a
• A u to a n t i b o d i e s a g a i n s t in t e r c e l l u l a r j u n c t i o n s o f k e r a l i n o c y t e s

P e m p h ig o id • L ik e p e m p h ig u s , b u t la rg e r b u lla e o n a b d o m e n a n d g ro in

I m p e ti g o • H o n e y c o l o r e d c r u s t , s u p e r f i c i a l s k i n i n f e c ti o n
• S t a p h y l o c o c c u s a u r e u s o r G r o u p A b c t a - h c m o l y t i c S t r e p to c o c c i

P it y r i a s i s • M a y b e o f v ira l o rig in
• H e r a l d p a t c h — s p r e a d s a l o n g U c x u r a l li n e s

R osacea • L a rg e , re d n o se

X a n th o m a • H y p e rlip id c m iu , fo a m y h is tio c y te s

C a p illa ry h e m a n g io m a • “ S a lm o n p a tc h e s ” a n d s to rk b ite s s p o n ta n e o u s ly re g re s s e s
• “ S tr a w b e r r y h e m a n g i o m a s " — i n i t i a l l y g r o w s , la t e r r e g r e s s e s

C a v e rn o u s h e m a n g io m a • “ P o rt-w in e s la in ” s e e n in S t u r g e - W e b e r s y n d r o m e d o e s n o t re s o lv e
s p o n ta n e o u s ly

C a f ti - a u - la it s p o t s • S e e n in N e u r o f i b r o m a t o s i s T y p e 1 ( v o n R e c k l i n g h a u s e n d i s e a s e )

V i t il ig o • Irre g u la r d e p ig m e n ta tio n

Im p e tig o is a n in fe c tio n c a u s e d b y g r o u p A b e ta -h e m o ly tic s tre p to co c c i o r

c o a g u la s e - p o s itiv e Staphylococcus aureus. T h e o r g a n is m s a re th o u g h t to e n te r
th ro u g h d a m a g e d s k in a n d a re tr a n s m itte d th ro u g h d ire c t c o n ta c t. It is a h ig h ly
in fe c tio u s s k in in fe c tio n th a t is m o s t c o m m o n in p re -s c h o o l-a g e d c h ild re n ( a g e d 2
to 5 y e a r s ) d u r in g w a r m w e a th e r . Im p e tig o u s u a lly a p p e a rs o n th e fa c e , e s p e c ia lly
a r o u n d a c h ild 's n o s e a n d m o u th . It s ta r ts a s a re d s o r e th a t q u ic k ly ru p tu r e s , o o z e s
fo r a fe w d a y s a n d th e n fo r m s a y e llo w is h - b r o w n c r u s t th a t lo o k s lik e h o n e y o r b ro w n
s u g a r . It te n d s to g r o w a n d s p r e a d . Im p e tig o is c o n ta g io u s . T h e in fe c tio n is c a r rie d
in th e flu id th a t o o z e s fr o m th e b lis te r s . R a re ly , im p e tig o m a y fo r m d e e p e r s k in
u lc e rs .
d is o r d e r s 235

R e c u r r e n t p e p tic u lc e rs o r p e p tic u lc e rs in a b e r r a n t s ite s s u c h a s th e

je ju n u m is s u g g e s tiv e o f:

• C u s h in g s y n d r o m e
• a c r o m e g a ly
• S ip p le s y n d r o m e
• Z o llin g e r - E llis o n s y n d r o m e

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a ri I • V o lu m e 1 3 • © 2 0 1 7
 • Z o llin g e r -E llis o n s y n d ro m e
Z o llin g e r- E llis o n s y n d ro m e ( Z E S ) is a ra re d is o r d e r th a t c a u s e s tu m o r s in th e
p a n c re a s a n d d u o d e n u m a n d u lc e r s in th e s to m a c h a n d d u o d e n u m . T h e p a n c r e a s is
a g la n d lo c a te d b e h in d th e s to m a c h . It p r o d u c e s e n z y m e s th a t b r e a k d o w n ta t,
p r o te in , a n d c a r b o h y d r a te s fro m fo o d , a n d h o r m o n e s lik e in s u lin th a t b r e a k d o w n
s u g a r . T h e d u o d e n u m is th e fir s t p a r t o f th e s m a ll in te s tin e .
P e p tic u lce rs ( c irc u m s c r ib e d le s io n s in th e m u c o s a l m e m b r a n e ) c a n d e v e lo p in th e
lo w e r e s o p h a g u s , s to m a c h , p y lo r u s , d u o d e n u m , o r je ju n u m . A b o u t 8 0 % o f a ll p e p tic
u lc e r s a r e d u o d en al u lc e rs , a n d o c c u r m o s t c o m m o n ly in m e n b e tw e e n th e a g e s of
2 0 a n d 5 0 . G as tric u lc e rs , w h ic h a ffe c t th e s to m a c h m u c o s a , a re m o s t c o m m o n in
m id d le - a g e d a n d e ld e r ly m e n . E s o p h ag eal u lc e r s a re c a u s e d b y th e r e p e a te d
r e g u r g ita tio n o f s to m a c h a c id (H C L ) in to th e lo w e r p a r t o f th e e s o p h a g u s .
E x c e p t fo r p e p tic u lc e r s o f th e s to m a c h , p e p tic u lc e r s a re a lw a y s a s s o c ia te d w ith
h y p e r s e c r e tio n o f g a s tr ic a c id a n d p e p s in . U lc e r a tio n is c lo s e ly r e la te d to g a s tr ic
H e lic o b a c te r p y lo ri in fe c tio n , w h ic h a ffe c ts e s s e n tia lly a ll p a tie n ts w ith d u o d e n a l
u lc e r s a n d th e m a jo r ity o f p a tie n ts w ith g a s tr ic u lc e rs .
P e p tic u lc e r s a r e s o m e tim e s as s o ciate d w ith :
• T h e u s e o f a s p irin a n d N S A ID s • P r im a r y h y p e r p a r a th y r o id is m
c .. • M u ltip le e n d o c r in e n e o p la s ia (M E N ) ty p e
• b m o K in g I (y v e rm e r s y n d ro m e )
• Z o llin g e r- E llis o n s y n d r o m e
T h e m o st c o m m o n s y m p to m o f a p e p tic u lc e r is p a in . If th e e r o s io n is s u ffic ie n tly
s e v e r e , b lo o d v e s s e ls in th e s to m a c h w a ll a r e d a m a g e d , a n d b le e d in g o c c u rs in to th e
s to m a c h its e lf ( th is is c a lle d a b le e d in g u lc e r ). In e x tr e m e c a s e s , a p e p tic u lc e r c a n
le a d to p e rfo ra tio n , w h ic h is a h o le e n tire ly th ro u g h th e w a ll o f th e G l tr a c t. T h is w ill
c a u s e a n a c u te p e r ito n itis w h ic h c a n le a d to d e a th .
Im p o rta n t: T h e m o st c o m m o n c o m p lic a tio n o f p e p tic u lc e r s is h e m o r r h a g e . It is
m o s t lik e ly w ith d u o d e n a l u lc e r s . M a lig n a n t c h a n g e is u n co m m o n .
d is o r d e r s 236

V a s o p r e s s in is p r o d u c e d in w h ic h o f th e fo llo w in g lo c a tio n s ?

• p a r a v e n tr ic u la r n u c le i o f th e h y p o th a la m u s
• s u p r a c h ia s m a tic n u c le i o f t h e h y p o th a la m u s
• a r c u a te n u c le i o f t h e h y p o th a la m u s
• s u p r a o p tic n u c le i o f th e h y p o th a la m u s
• p r e o p tic n u c le i o f t h e h y p o th a la m u s

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • supraoptic nuclei of the hypothalam us
T h e m o s t c o m m o n d is e a s e o f m a n re la te d to a n tid iu re tic h o rm o n e (va so p re s s in ) is diabetes
insipidus. T h is c o n d itio n c a n a ris e fro m e ith e r o f tw o situ a tio n s:
• Hypothalam ic ("ce n tra l") d ia b e te s in s ip id u s re su lts fro m a d e fic ie n c y in s e c re tio n of
a n tid iu re tic h o rm o n e fro m th e p o s te rio r p ituita ry. C a u s e s o f th is d is e a s e inclu d e h ead
tra u m a , and in fe ctio n s o r tu m o rs invo lvin g th e h yp o tha lam us.
• N ephrogenic d ia b e te s in sip id u s o ccu rs w he n th e k id n e y is u n a b le to re sp on d to a n tid iu re tic
h o rm o n e . M o st c o m m o n ly, th is re su lts fro m so m e typ e o f renal d ise a se , b u t m u ta tio n s in th e
A D H re c e p to r g en e o r in th e g e n e e n co d in g a q u a p o rin -2 h ave a ls o b een d e m o n s tra te d in
a ffe c te d h u m an s.
Note: ADH (a n tid iu re tic h o rm o ne ) is p ro d u ce d in th e s u p ra o p tic n uclei o f th e h yp o th a la m u s but
se c re te d by th e p o s te rio r p ituita ry. A n tid iu re tic h o rm o n e b in d s to re c e p to rs on c e lls in the
co lle ctin g d u c ts o f th e k id n e y a nd p ro m o te s re a b so rp tio n o f w a te r b a ck in to th e circu la tio n . In the
a b se n ce o f a n tid iu re tic h orm o ne , th e co lle c tin g d u cts a re v irtu a lly im p e rm e a b le to w a te r, a nd it
flo w s o u t a s u rine.
Dl is ch a ra c te riz e d b y e x c e s s iv e u rin a tio n (polyuria) d u e to an in a bility o f th e kidn ey to resorb
w a te r p ro p e rly from th e urine.
Dl sh o u ld not be co nfu sed w ith diabetes m ellitus, w h ic h re su lts fro m insu lin d e fic ie n c y or
re sista n ce le a d in g to high b lo o d g lu cose . D ia b e te s in s ip id u s a nd d ia b e te s m e llitu s a re unrelated,
a lth o u g h th e y ca n h ave s im ila r s ig n s a nd sym p to m s, like e xce s s iv e th irs t a nd e xce s s iv e u rina tio n.
Diabetes m ellitus (D M ) is fa r m o re c o m m o n th an D l. D M h as tw o fo rm s , re fe rre d to a s ty p e 1
d ia b e te s (fo rm e rly ca lle d ju v e n ile d ia be te s, o r in su lin -d e p e n d e n t d ia b e te s m ellitus, o r ID D M ) and
ty p e 2 d ia b e te s (fo rm e rly ca lle d a d u lt-o n s e t d ia be te s, o r n o n in s u lin -d e p e n d e n t d ia b e te s m ellitus,
o r N ID D M ). Dl is a d iffe re n t fo rm o f illn e ss a lto g e th e r.
1. T h e m o st im p o rta n t v a ria b le re g u la tin g a n tid iu re tic h o rm o n e se cre tio n is plasma
osmolarity, o r th e c o n c e n tra tio n o f so lu te s in b lo o d . O s m o la rity is s e n se d in th e
h y p o th a la m u s by n e u ro n s kn ow n as a n o s m o re ce p to rs, a nd th o s e neu ro ns, in tu rn ,
stim u la te se cre tio n fro m th e n e u ro n s th a t p ro d u c e a n tid iu re tic h o rm o n e .
• A n g io te n s in II a lso s tim u la te s v a s o p re s s in s e c re tio n
• E th a n o l re d u c e s v a s o p re s s in s e c re tio n a t n e u ro h y p o p h y s e a l n e rve te rm in a ls
2. S e c re tio n o f a n tid iu re tic h o rm o n e is a lso s tim u la te d b y d e c re a s e s in b lo o d p re ssu re
a nd v o lu m e , co n d itio n s s e n s e d b y s tre tch re c e p to rs in th e h e a rt a n d large a rte rie s.
d is o rd e rs 237

In fe c tio u s m o n o n u c le o s is is a b e n ig n , s e lf -lim it in g d is o r d e r c a u s e d
by:

• v a r ic e lla - z o s te r v ir u s ( V Z V )
• h e r p e s s im p le x v ir u s ty p e 1 ( H S V - 1 )
• c y to m e g a lo v ir u s ( C M V )
• E p s te in - B a r r v ir u s ( E B V )

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • E p s te in -B a rr v iru s (E B V )
In fe c tio u s m o n o n u c le o s is is a v iral in fec tio n c a u s in g h ig h te m p e ra tu re , s o r e th ro a t,
g e n e r a liz e d ly m p h a d e n o p a th y , a n d o fte n h e p a to s p le n o m e g a ly . It is c a u s e d b y th e
E p s te in - B a r r v ir u s (E B V ), w h ic h h a s a n a ffin ity fo r B ly m p h o c y te s . E B V is tr a n s m itte d
b y c lo s e h u m a n c o n ta c t, fr e q u e n tly w ith th e s a liv a d u r in g k is s in g . In fe c tio u s
m o n o n u c le o s is o cc u rs p r in c ip a lly in la te a d o le s c e n ts or young a d u lts .
H e m a to lo g ic a lly , th e r e is re la tiv e ly m p h o c y to s is w ith a ty p ic a l a c tiv a te d T
ly m p h o c y te s ( m o n o n u c le o s is c e lls ).
T h e a ty p ic a l ly m p h o c y te s s e e n in th e b lo o d , s o c h a r a c te r is tic o f th is d is e a s e , a re
m a in ly E B V -s p e c ific C D 8 + c y to to x ic T cells, b u t a ls o in c lu d e C D 1 6 + N K c e lls . T h e
re a c tiv e p r o life r a tio n o f T c e lls is la r g e ly c e n te r e d in th e ly m p h o id tis s u e s , w h ic h
a c c o u n ts f o r th e ly m p h a d e n o p a th y a n d s p le n o m e g a ly .
A s s o c ia te d oral c h a n g es inclu d e: a c u te p h a r y n g itis a n d to n s illitis th a t m a y c a u s e
c o a tin g w ith a g r a y -w h ite e x u d a tiv e m e m b r a n e ; e n la r g e m e n t o f ly m p h n o d e s in th e
n e c k , p a la ta l p e te c h ia e .
In fe c tio u s m o n o n u c le o s is is m a r k e d b y a n u m b e r o f s e ru m a n tib o d ie s :
• A n ti-E B V a n tib o d ie s
• H e te r o p h il a n tib o d ie s ( h e te r o p h il a g g lu tin in s )
* * * T h is a n tib o d y e v e n tu a lly a p p e a rs in th e s e r u m o f m o re th a n 8 0 % o f th e p a tie n ts
w ith in fe c tio u s m o n o n u c le o s is , h e n c e it is h ig h ly d ia g n o s tic o f th e d is o r d e r .
1. S p o n ta n e o u s re c o v e ry u s u a lly o c c u rs in 2 to 3 w e e k s . N o a n tiv ira l
th e ra p y is n e c e s s a r y fo r u n c o m p lic a te d in fe c tio u s m o n o n u c le o s is a n d
th e r e is no E B V vaccin e.
2. T h e s p leen is e s p e c ia lly s u s c e p tib le to tr a u m a tic ru p tu re .
3. R e m e m b e r : E B V is a s s o c ia te d w ith B u rk itt's ly m p h o m a a n d
n a s o p h a ryn g e a l c arcin o m a . It is a ls o a s s o c ia te d w ith h a iry
leu k o p lak ia.
4. P a tie n ts w ith a n ac u te in fe c tio u s d is e a s e w ill h a v e a r is in g a n tib o d y
tite r.
d is o r d e r s 238

A lt h o u g h a s th m a c a n s tr ik e a t a n y a g e , h a lf o f a ll c a s e s fir s t o c c u r in:

• m id d le a g e a d u lts
• te e n a g e rs
• e ld e r ly p e r s o n s
• c h ild r e n u n d e r a g e 1 0

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • children under age 10
Asthma is a c h ro n ic in fla m m a to ry d iso rd e r of th e a irw a y s th a t c a u s e s re c u rre n t e p iso d e s
o f w h e e z in g , b re a th le s s n e s s , c h e s t tig h tn e s s , a n d c o u g h , p a rtic u la rly a t n ig h t a n d /o r in
th e e a rly m o rn in g s. T h e h a llm a rk s of th e d is e a s e are: in c re a s e d a irw a y re s p o n s iv e n e s s to
a va rie ty of s tim u li, re s u ltin g in e p is o d ic b ro n c h o c o n s tric tio n (bronchospasm);
in fla m m a tio n o f th e b ro n c h ia l w a lls ; an d in c re a s e d m u c u s s e c re tio n .
A s th m a m a y be c a te g o riz e d into atopic (e v id e n c e o f a lle rg e n se n s itiz a tio n , o fte n in a
p a tie n t w ith a h is to ry o f a lle rg ic rh in itis, e c z e m a ) an d non-atopic (w ith o u t e v id e n c e of
a lle rg e n se n s itiz a tio n ). In e ith e r type, e p is o d e s o f bronchospasm c a n be trig g e re d by
d iv e rs e m e ch a n is m s . A s th m a m ay a lso be c la s s ifie d a c c o rd in g to th e a g e n ts o r e v e n ts th a t
trig g e r b ro n c h o c o n s tric tio n . T h e s e in c lu d e se a s o n a l, e x e rc is e -in d u c e d , d ru g -in d u c e d (e.g.,
a s p irin ), an d o c c u p a tio n a l a sth m a , a n d a s th m a tic b ro n c h itis in s m o k e rs .
In a sth m a , b ro n c h ia l lin in g s o v e rre a c t to v a rio u s s tim u li, c a u s in g s m o o th m u s c le s p a sm s
(bronchospasms) th a t s e v e re ly c o n s tric t th e a irw a y s . W h e n th e h y p e rs e n s itiv e individua l
in h a le s a trig g e rin g s u b s ta n c e (e x trin s ic a lle rg e n ), a b n o rm a l a n tib o d ie s s tim u la te mast
cells in th e lung in te rs titiu m to re le a s e both histamine an d th e slow-reacting substance
of anaphylaxis (S R S -A ). B oth of th e s e s u b s ta n c e s c a u s e s w e llin g o f th e b ro n c h ia l
s m o o th m u s c le th e re b y n a rro w in g th e b ro n c h ia l lu m e n . O n in h a la tio n , th e n a rro w e d
b ro n c h ia l lu m e n can still e x p a n d slig h tly , a llo w in g a ir to re a ch th e a lv e o li. O n e x h a la tio n ,
in c re a s e d in tra th o ra c ic p re s s u re c lo s e s th e b ro n c h ia l lum en c o m p le te ly . M u c u s fills the
lung base s, in h ib itin g a lv e o la r v e n tila tio n . B lood, s h u n te d to th e a lv e o li in o th e r lung parts,
s till c a n 't c o m p e n s a te fo r d im in is h e d v e n tila tio n .
1. Important: Nitrous oxide is s a fe to a d m in is te r to p e o p le w ith a s th m a a nd is
e s p e c ia lly ind ic a te d fo r p a tie n ts w h o s e a s th m a is trig g e re d by anxiety.
2. If patient is taking steroids, c o n s u lt p h y s ic ia n fo r th e p o s s ib le n e e d fo r
c o rtic o s te ro id a u g m e n ta tio n .
3. T h e in h a la tio n of a short-acting selective beta2-agonist (te rb u ta lin e ,
a lb u te ro l) is th e p re fe rre d tre a tm e n t fo r an acute asthmatic attack.
4. Status asthmaticus is a p a rtic u la rly s e v e re e p is o d e o f a s th m a , u s u a lly
re q u irin g h o s p ita liz a tio n , th a t d o e s n o t re s p o n d a d e q u a te ly to o rd in a ry
th e ra p e u tic m e a su re s. C h ro n ic p a rtia l a irw a y o b s tru c tio n m a y lead to death
from re s p ira to ry acidosis.
d is o r d e r s 239

W h ic h o f th e fo llo w in g is c h a r a c te r iz e d b y a b r e a k d o w n in s e lf­
to le r a n c e to th y r o id a u to -a n tig e n s , m o s t im p o r ta n tly th e T S H
re c e p to r ?

• G r a v e s ' d is e a s e
• th y r o id itis
• m yxedem a
• c r e tin is m

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • G raves' d isease
H y p e r th y r o id is m ( o r th y r o to x ic o s is ) is a n im b a la n c e o f m e ta b o lis m c a u s e d b y
o v e r p r o d u c tio n o f th y ro id h o r m o n e ( th y r o x in e - T 4 a n d tr iio d o th y r o n in e - T 3 ) . E x c e s s iv e
p r o d u c tio n o f th e th y ro id h o rm o n e th y r o x in p ro d u c e s th e s y m p to m s of
h y p e r th y ro id is m . T h e p r im a r y ro le o f th y r o x in e is to s tim u la te c e llu la r m e ta b o lis m ,
g ro w th , a n d d iffe r e n tia tio n o f a ll tis s u e s . In e x c e s s , th e r e fo r e , it le a d s to h igh basal
m e ta b o lis m , fa tig u e , w e ig h t lo s s , e x c ita b ility , e le v a te d te m p e r a tu r e , a n d g e n e r a liz e d
o s te o p o ro s is . O r a l m a n ife s ta tio n s a re n ot to o r e m a r k a b le , b u t if th e d is tu r b a n c e
b e g in s in th e e a r ly y e a r s o f life , p re m a tu re e ru p tio n o f th e te e th a n d lo ss o f th e
d e c id u o u s d e n titio n a re c o m m o n fin d in g s .
T w o ty p e s of h y p e rth y ro id is m :
1 . G raves' d isease is th e m o s t c o m m o n c a u s e o f e n d o g e n o u s h y p e rth y ro id is m .
W o m e n a re a ffe c te d a s m u c h a s 10 tim e s m o r e fr e q u e n tly th a n m e n . It is a th y ro id
- s p e c ific a u to im m u n e d is o r d e r in w h ic h th e b o d y m a k e s a n tib o d ie s to th e th y r o id -
s tim u la tin g h o r m o n e r e c e p to r ( T S H R ) , le a d in g to h y p e r th y r o id is m , o r a n
a b n o r m a lly s tr o n g r e le a s e o f h o r m o n e s fr o m th e th y r o id g la n d . N o rm a lly , th e
re le a s e o f th y r o id h o r m o n e s is m e d ia te d b y th y r o id - s tim u la tin g h o r m o n e ( T S H ) , a
h o r m o n e s e c re te d b y th e p itu ita r y g la n d th a t b in d s to T S H R to s tim u la te th e
th y ro id to r e le a s e th y r o id h o r m o n e s . T h is n o r m a l c y c le is s e lf- r e g u la tin g : th e
h o r m o n e s s e c re te d b y th e th y r o id k e e p m o r e T S H fro m b e in g p r o d u c e d . T h e
a u to a n tib o d ie s p r o d u c e d in G r a v e s ' d is e a s e a re n ot s u b je c t to n e g a tive
fee d b ack, s o th e y c o n tin u e to b e p r o d u c e d a n d b in d to T S H R e v e n w h e n th y r o id
h o r m o n e le v e ls r is e to o h ig h . T h e s e a n tib o d ie s a c t a s a g o n is ts , s tim u la tin g m o re
h o r m o n e s to b e r e le a s e d a n d th u s le a d in g to h y p e r th y r o id is m . T h e r e a re a w id e
ra n g e o f s y m p to m s fro m a n x ie ty a n d r e s tle s s n e s s to in s o m n ia a n d w e ig h t lo s s . In
a d d itio n , th e e y e b a lls m a y b e g in to p r o tr u d e ( e x o p h th a lm o s ) c a u s in g irr ita tio n a n d
te a rin g .
2. P lu m m e r's d is e a s e ( to x ic n o d u la r g o ite r ) a r is e s fro m a lo n g - s ta n d in g s im p le
g o ite r a n d o c c u r s m o s t o fte n in th e e ld e r ly . S y m p to m s a re th o s e of
h y p e r th y r o id is m , b u t th e p r o tru d in g e y e b a lls s e e n in G r a v e s ' d is e a s e do not
o c c u r. R is k fa c to r s in c lu d e b e in g fe m a le a n d o v e r 6 0 y e a r s o ld . T h is d is o r d e r is
n e v e r seen in ch ild ren .
in fla m m a tio n & n e c ro s is 240

T h e fir s t w h ite b lo o d c e lls o n th e s c e n e d u rin g th e a c u te o r e a r ly

s ta g e o f in fla m m a tio n a r e th e :

• b a s o p h ils
• e o s in o p h ils
• n e u tr o p h ils
• m o n o c y te s

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • n e u tr o p h ils
N e u tr o p h ils , th e m o s t n u m e r o u s o f th e w h ite b lo o d c e lls (5 0 -7 5 % ), in c r e a s e
d r a m a tic a lly in n u m b e r in r e s p o n s e to in fe c tio n a n d in fla m m a tio n (in fa c t, th e y
a r e th e p r im a r y c o n s titu e n t o f p u s ) . T h e s e h ig h ly m o b ile c e lls a r e a t tr a c te d to
a r e a s o f in fla m m a t io n b y c h e m o ta x is a n d th e y id e n tify th e f o r e ig n a n t ig e n a n d
a t ta c h to it. T h e y s ta r t e n g u lfin g th e in v a d in g o r g a n is m s a n d a tt e m p t to c o n ta in
th e in fe c t io n in a s m a ll s p a c e . If th e in fe c t io n c o n tin u e s , m o n o c y t e s , a n o th e r
ty p e o f w h ite b lo o d c e ll w ith e v e n g r e a te r a b ility to e n g u lf o r g a n is m s , a r r iv e in
in c r e a s in g q u a n tit ie s .
_ 1. N u m e r o u s s u b s ta n c e s h a v e b e e n id e n tif ie d a s c h e m o ta c tic fo r
n e u t r o p h ils . T h e s e in c lu d e th e c o m p le m e n t s y s te m p r o te in s C 3 a a n d
C 5 a w h ic h a r e k n o w n a s a n a p h y la to x in s , th a t is , th e y in d u c e a
p h y s io lo g ic a l r e s p o n s e t h a t r e s u lts in b lo o d v e s s e l d ila tio n ,
h y p o te n s io n , in c r e a s e d v a s c u la r p e r m e a b ility , e tc .
2 . R e m e m b e r : C h e m o ta x is is a p ro c e s s o f a ttr a c tin g a n d re c ru itin g
c e lls in w h ic h a c e ll m o v e s to w a r d a h ig h e r c o n c e n tr a tio n o f a
c h e m ic a l s u b s ta n c e .
3 . In o r d e r t o d e s tr o y its ta r g e t, n e u tr o p h ils u s e o x y g e n - d e p e n d e n t
k illin g m e c h a n is m s a s w e ll a s d e fe n s in m o le c u le s .
4 . T h e o x y g e n - d e p e n d e n t k illin g m e c h a n is m s in v o lv e th e u s e o f
s u p e r o x id e , m y e lo p e r o x id e , h y d r o g e n p e r o x id e , a n d N A D P H o x id a s e .
R e m e m b e r : N A D P H o x id a s e is a m u lti u n it e n z y m e t h a t p r o d u c e s
s u p e r o x id e r a d ic a ls a n d c o n tr ib u te s to th e k illin g o f in te r n a liz e d
p a th o g e n s in n e u tr o p h ils . A d e fic ie n c y in a n y o f th e N A D P H s u b u n it s
c a n b e a c a u s e o f c h r o n ic g r a n u lo m a to u s d is e a s e , a n
im m u n o d e fic ie n c y d is e a s e . N o te : N A D P H is m a d e in th e p e n to s e
p h o s p h a te p a th w a y .
5. D e fe n s in s a r e a fa m ily o f a n tim ic r o b ia l p e p t id e s 3 5 -4 0 a m in o a c id s
lo n g t h a t c a n p e n e tr a t e m ic r o b ia l m e m b r a n e s a n d d is r u p t th e ir
in te g r ity .
in fla m m a tio n & n e c r o s is 241

A b s c e s s e s a re lo c a liz e d c o lle c tio n s o f p u r u le n t in fla m m a to r y tis s u e

c a u s e d b y s u p p u r a tio n th a t b u rie s in a tis s u e , a n o r g a n , o r a c o n fin e d
space.
A b s c e s s e s a re p r o d u c e d b y d e e p s e e d in g o f p y o g e n ic b a c te r ia in to a
tis s u e .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s t a t e m e n t is tr u e , th e s e c o n d is f a ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s ta t e m e n t s a r e tr u e
Abscesses h a v e a c e n tr a l r e g io n th a t a p p e a r s a s a m a s s o f n e c r o tic
le u k o c y t e s a n d t is s u e c e lls . T h e r e is u s u a lly a z o n e o f p r e s e r v e d n e u tr o p h ils
a r o u n d t h is n e c r o t ic fo c u s , a n d o u t s id e t h is r e g io n v a s c u la r d ila t io n a n d
p a re n c h y m a l and f ib r o b la s t ic p r o lif e r a t io n o c c u r, in c lu d in g c h r o n ic
in f la m m a t io n a n d r e p a ir . In t im e t h e a b s c e s s m a y b e c o m e w a lle d o f f a n d
u ltim a te ly r e p la c e d b y c o n n e c t iv e t is s u e .
A c y s t is a n a b n o r m a l s a c w it h in t h e b o d y c o n t a in in g a ir o r flu id . It is lin e d
w it h e p ith e liu m .
A g r a n u lo m a is a tu m o r c o m p o s e d o f g r a n u la t io n t is s u e th a t is u s u a lly
a s s o c ia te d w ith u lc e r a te d in fe c tio n s . E p ith e lio id c e lls a n d g ia n t c e lls a r e
d e r iv e d f r o m m a c r o p h a g e s a n d a r e c h a r a c t e r is t ic c e lls fo u n d in g r a n u lo m a s .
L y m p h o c y t e s , p la s m a c e lls , a n d f ib r o b la s t s s u r r o u n d th e n o d u le o f e p ith e lio id
c e lls .
A t u m o r is a g r o w th o f tis s u e t h a t f o r m s a n a b n o r m a l m a s s . In g e n e r a l,
t u m o r s ( a ls o k n o w n a s n e o p la s m s ) a p p e a r t o b e c a u s e d b y a b n o r m a l
r e g u la tio n o f c e ll d iv is io n . T u m o r s g e n e r a lly p r o v id e n o u s e fu l fu n c t io n a n d
g r o w a t th e e x p e n s e o f h e a lt h y tis s u e s .
A n u lc e r is a lo c a l d e f e c t, o r e x c a v a tio n , o f th e s u r fa c e o f a n o r g a n o r tis s u e
t h a t is p r o d u c e d b y th e s lo u g h in g ( s h e d d in g ) o f in f la m e d n e c r o t ic tis s u e .
U lc e r a tio n c a n o c c u r o n ly w h e n t is s u e n e c r o s is a n d r e s u lt a n t in fla m m a tio n
e x is t o n o r n e a r a s u r f a c e .
in fla m m a tio n & n e c ro s is 242

G a s g a n g r e n e o c c u r s a s a r e s u lt o f in fe c tio n b y C lo strid iu m
p erfrin g e n s.
C lo s tr id ia a r e o b lig a te a e r o b e s , g r a m -n e g a tiv e b a c te r ia c a p a b le o f
e n d o s p o r e p r o d u c tio n .

• b o th s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y !► d e n ta l decks
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
M y o n e c r o s is o r g a s g a n g r e n e r e s u lts fr o m lo c a l in fe c tio n w it h th e a n a e r o b ic ,
s p o r e - f o r m in g , g r a m - p o s it iv e r o d Clostridium perfringens. T h e s e b a c te r ia
u n d e r a n a e r o b ic c o n d it io n s p r o d u c e to x in s t h a t k ill n e a r b y c e lls . T h is r a r e
in fe c tio n g e n e r a lly o c c u r s a t th e s it e o f t r a u m a o r a r e c e n t s u r g ic a l w o u n d . T h e
o n s e t o f g a s g a n g r e n e is s u d d e n a n d d r a m a t ic . In f la m m a t io n b e g in s a t th e
s it e o f in fe c tio n a s a p a le t o b r o w n is h - r e d a n d e x t r e m e ly p a in fu l t is s u e s w e llin g .
G a s m a y b e f e lt in th e t is s u e a s a c r a c k ly s e n s a t io n w h e n th e s w o lle n a r e a is
p r e s s e d w it h th e fin g e r s . T h e m a r g in s o f th e in fe c te d a r e a e x p a n d s o r a p id ly
t h a t c h a n g e s a r e v is ib le o v e r a f e w m in u te s . T h e in v o lv e d t is s u e is c o m p le t e ly
d e s tr o y e d . R e m e m b e r : G a n g r e n e is t h e d e a t h o f tis s u e , u s u a lly a s s o c ia t e d
w it h lo s s o f b lo o d s u p p ly to th e a ff e c t e d a r e a . It is a fo r m o f n e c r o s is c o m b in e d
w it h p u t r e f a c t io n ( d e c o m p o s it io n o r r o ttin g ) .
S y s t e m ic s y m p t o m s d e v e lo p e a r ly in th e in fe c tio n . T h e s e c o n s is t o f s w e a tin g ,
fe v e r , a n d a n x ie ty . If u n tr e a te d , th e in d iv id u a l d e v e lo p s a s h o c k - lik e s y n d r o m e
w it h d e c r e a s e d b lo o d p r e s s u r e ( h y p o te n s io n ) , r e n a l fa ilu r e , c o m a , a n d fin a lly
d e a th .
N o te : It is p r e v e n t e d b y p r o p e r w o u n d c a r e .
„ 1. C lo s tr id ia a r e o b lig a t e a n a e r o b e s , g r a m - p o s it iv e b a c t e r ia c a p a b le o f
e n d o s p o r e p r o d u c tio n .
2 . C lo s t r id iu m b a c t e r ia p r o d u c e m a n y d if f e r e n t t o x in s ( i.e ., a lp h a ,
b e ta , e p s ilo n , io ta ) . T h e m o s t im p o r t a n t is th e a lp h a to x in
( le c ith in a s e ) , w h ic h d a m a g e s c e ll m e m b r a n e s , in c lu d in g t h o s e o f
e r y th r o c y te s , r e s u ltin g in h e m o ly s is .
3. R e m e m b e r:
• Clostridium tetani c a u s e s te t a n u s ( a ls o k n o w n a s lo c k ja w )
• Clostridium botulinum c a u s e s b o t u lis m
• Actinomyces israelii c a u s e s a c t in o m y c o s is
in fla m m a tio n & n e c r o s is 243

W h ic h o f th e fo llo w in g ty p e s o f n e c r o s is is th e m o s t b a s ic a n d m o s t
com m on?

• c o a g u la tio n
• liq u e fa c tio n

• caseous
• g a n g re n o u s
• fib r in o id

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • coagulation
N e c ro tic c e lls a re u n a b le to m a in ta in m e m b r a n e in te g r ity a n d th e ir c o n te n ts o fte n le a k
o u t, a p ro c e s s th a t m a y e lic it in fla m m a tio n in th e s u r ro u n d in g tis s u e . T h e e n z y m e s
th a t d ig e s t th e n e c ro tic c e lls a re d e riv e d fro m th e ly s o s o m e s o f th e d y in g c e lls
th e m s e lv e s a n d fro m th e ly s o s o m e s o f le u k o c y te s th a t a re c a lle d in a s p a rt o f th e
in fla m m a to r y re a c tio n .
N u c le a r c h a n g e s a p p e a r in o n e o f th re e p a tte rn s (k a ry o ly s is , p y k n o s is , or
k a ry o rrh e x is ), a ll d u e to n o n s p e c ific b re a k d o w n o f D N A .
Note: C oagulative necrosis is th e m ost basic a n d most com m on ty p e o f n e c ro s is . It
d e v e lo p s when d e n a tu ra tio n of p r o te in s is th e d o m in a n t p ro c e s s , w h e re a s
liquefactive necrosis d e v e lo p s w h e n e n z y m a tic d ig e s tio n is th e d o m in a n t p ro c e s s .
W h e n la r g e r a re a s o f tis s u e s a re d e a d , th e tis s u e is c a lle d gangrene. Note: A
lo c a liz e d a r e a o f c o a g u la tiv e n e c ro s is is c a lle d a n infarct.
T ype of C au ses M o s t L ik e ly S ite s I n v o lv e d
N e c ro s is

C o ag u la tio n Isch em ia (lo s s o f b lo o d su p p ly ) H e art o r K idney

L iq u efac tio n S up p u ration , ab s ce s se s a n d isc h e m ic in jury D rain o r s p in al co rd

to th e C N S

C a se o u s G ran u lo m a to u s in fla m m a tion (ty p ica l o f T B ) G ran u lo m a to u s in fla m m a to ry site s

G a n g ren o u s P u tre fac tiv e b a c te ria u c ting o n n ec ro tic L o w e r ex tre m itie s o r b o w el

b o w e l o r ex tre m ity

F ib rin o id Im m u n e-m e d ia tc d v a s cu la r d am ag e A rte ria l w alls

F at In ju red pa n c re as , trau m a to a d ip o se tissu e A d ipo s e tiss ue, p a n c re as

Remember:
1. Autolysis ta k e s p la c e w h e n th e s o u rc e o f th e h y d r o ly tic e n z y m e s is th e d y in g c e ll's
o w n ly s o s o m e s .
2. H eterolysis o c c u rs w h e n th e h y d r o ly tic e n z y m e s c o m e fro m o th e r in filtra tin g c e lls .
in fla m m a tio n & n e c r o s is 244

E p it h e lio id c e lls a n d g ia n t c e lls a re d e r iv e d fr o m m a c r o p h a g e s a n d

a re im p o r ta n t in th e d e v e lo p m e n t of:

• in it ia l in fla m m a tio n
• g r a n u lo m a t o u s in fla m m a tio n

• a c u te in fla m m a tio n
• s u b a c u t e in fla m m a tio n

M IC R O B IO L O G Y /P A T H O L O G Y d M e n ta ld e c k s
P a rt I ‘ V o lu m e 1 3 * © 2 0 1 7
 • g r a n u lo m a to u s in fla m m a tio n
G r a n u lo m a to u s in fla m m a tio n is a d is tin c tiv e p a tte r n o f c h ro n ic in fla m m a tio n a n d is
c h a r a c te r iz e d b y g ran u lo m a s , w h ic h a re n o d u la r c o lle c tio n s o f s p e c ia liz e d
m a c r o p h a g e s r e fe r re d to a s e p ith e lio id c e lls . G r a n u lo m a s a re u s u a lly s u r ro u n d e d
b y a c o lla r o f m o n o n u c le a r le u k o c y te s , p r in c ip a lly ly m p h o c y te s a n d o c c a s io n a lly
p la s m a c e lls . F r e q u e n tly , e p ith e lio id c e lls fu s e to fo r m m u ltin u c le a te d g ia n t c e lls
( L a n g e r h a n s g ia n t c e lls a n d fo r e ig n b o d y g ia n t c e lls ) in th e p e r ip h e r y o r s o m e tim e s in
th e c e n te r o f g ra n u lo m a s .
T u b e rc u lo s is is th e p r o to ty p e o f th e g r a n u lo m a to u s d is e a s e s . R e c o g n itio n o f th e
g r a n u lo m a to u s p a tte r n in b io p s y s p e c im e n is im p o r ta n t b e c a u s e o f th e lim ite d
n u m b e r o f p o s s ib le c o n d itio n s th a t c a u s e it a n d th e s ig n ific a n c e o f th e d ia g n o s is
a s s o c ia te d w ith th e le s io n s . N o te: G r a n u lo m a to u s in fla m m a tio n is c h a r a c te r is tic a lly
a s s o c ia te d w ith a r e a s o f caseo u s n ecro sis p r o d u c e d b y in fe c tio u s a g e n ts ,
p a r tic u la r ly M yc o b a c te riu m tu b e rc u lo s is .
r .x iiin p lc s o f D is e a s e s w ith G r a n u l o m a t o u s lu l l ;

D isease C ause T is s u e R e ac tio n

T u b e rc u lo s is M y c o b a c te riu m C 'as ea ting g r a n u l o m a (tu b e rc le ); f o c u s o f a c t i v a t e d m a c r o p h a g e s

tu b e rc u lo s is (e p ith e lio id cells), r i m m e d b y f i b r o b l a s t s , l y m p h o c y t e s ,
h is t io c y t e s , o c c a s io n a l I -a n g h n n s g ia n t c e lls .; c e n tr a l n e c r o s is
w ith a m o r p h o u s g r a n u la i d e b r is , a c id f a s t b a c illi

L ep ro sy M y c o b a c te riu m le p ra e A c i d f a s t b a c i l l i in m a c r o p h a g e s ; n n n e a s e a t i n g g r a n u l o m a s

S y p h ilis T re p o n e m a p a llid u m G um m a: m ic r o s c o p ic to g r o s s ly v is ib le le s io n , e n c lo s in g w a ll o f
h is tio c y te s : p la s m a c e ll in f iltr a te ; c e n tr a ] c e lls n e c r o tic w ith o u t
lo s s o f c e llu l a r o u tlin e

C a t- s c r a tc h G ra m - n e g a tiv e b a c illu s R o u n d e d o r s te lla te g r a n u lo m a c o n ta in in g c e n tr a l g r a n u la r

d is e a s e d e b ris a n d re c o g n iz a b le n e u tro p h ils , g ia n t c e lls u n c o m m o n

S a r c o id o s is U n k n o w n e tio lo g y N o n c as c a tln g g ra n u lo m a s w ith a b u n d a n t a c tiv a te d m a c ro p h a g e s

C r o h n d is e a s e Im m u n e rc a e tio n a g a in s t O c c a s io n a l n o n c a s e a tln g g r a n u lo m a s in th e w a ll o f th e
in te s tin a l b a c te r ia , s e lf i n t e s t i n e , w i t h d e n s e c h r o n i c i n f l a m m a t o r y in f i l t r a t e
a n tig e n s
in fla m m a tio n & n e c r o s is 245

In r e s p o n s e to a n in ju ry , m o n o n u c le a r in fla m m a to r y c e lls c o u p le d
w ith th e p ro d u c tio n o f fib r o u s c o n n e c tiv e tis s u e a r e in d ic a tiv e of:

• a c u te in fla m m a tio n
• c h r o n ic in fla m m a tio n

• edem a
• g a n g re n e

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • c hron ic in flam m atio n
C h ro nic inflam m atio n d e v e lo p s at a s ite of in ju ry th a t persists lo n g er th a n se v e ra l days.
It is m ore p ro life ra tiv e th a n exud a tive . N e cro sis c o m m o n ly o c cu rs and recurs. E x a m p le s of
c h ro n ic in fla m m a tio n in c lu d e c h ro n ic h e p a titis , c h ro n ic p y e lo n e p h ritis , a n d a u to im m u n e
d iseases. Note: G ran u lo m atou s inflam m atio n is a su b typ e of c h ro n ic in fla m m a tio n
c h a ra c te riz e d m o rp h o lo g ic a lly b y g ra n u lo m a s (e.g., T B , s a rc o id o s is , a n d silico sis).
A cu te inflam m atio n is th e in itia l re s p o n s e of tis s u e to injury, p a rtic u la rly b a c te ria l
in fe ctio n s, in v o lv in g vascu lar and cellular re s p o n se s. T h re e m a jo r p h e n o m e n a o ccur:
Increased vascu lar p erm eab ility w ith tis s u e e x u d a te fo rm e d , leu ko cytic cellular
infiltratio n (m a in ly n e u tro p h ils by c h e m o ta c tic a g e n ts C 5 a a nd C 3a), a nd repair (either
b y re g e n e ra tio n o r re p la c e m e n t). Local sig ns of a c u te in fla m m a tio n inc lu d e redness
(rubor), h eat (calor), sw ellin g (tu m o r), pain (d o lo r), a nd loss o f fun ction . System ic
e ffe c ts in c lu d e fe ve r, ta c h y c a rd ia , a nd leu k o c y to s is (e s p e c ia lly n e u tro p h ils ).
Rem em ber: O th e r c e lls in v o lv e d in acu te infla m m a tio n (s p e c ific a lly th e v a s c u la r phase)
in c lu d e b a s o p h ils , tis s u e m a s t ce lls, a nd p la te le ts . T h e s e c e lls release histam ine.
M a c ro p h a g e s a p p e a r iate in th e c e llu la r p h a s e a nd re p re s e n t a tra n s itio n b e tw e e n acute
a nd c h ro n ic in fla m m a tio n .

A nton M e d i a t o rs

A c u te In fla m m a tio n

In c re a s e d v a s cu la r p e rm e ab ility H ista m ine , b rn d y lan in . O i , C S a. le ttk o iiie u e v P A F .

su bs ta n ce P

V a so d ilatio n H ista m ine , p ro s ta g la n d in s . PA F . N ilu c ox ide

P a in B iad yk in itt. p io s la g la n d in s

L e u k o cy te a d h es io n I.T B 4 , IL -I. T N F -n lplin . C 5 a

L eu ko cy te c licm o lax is t'S a . C 3 t . lly-8. ( It e i n o k in c v P A F . L eu k otric n e B1

A cu te p ha s e te s p o u s e IL -1 .1 L -6 . T N F -alp h a

T is s u e da m a ge P to lea s es . fi e e ta ilic als , N O . n e u tro ph il g ran ule c o n ten ts

F e v er I L - l. T N F , p io s lag la n d in s

C h r o n ic In fl a m m a tio n

A ctiva tio n o f T c ell* , a n d m n e ro p h a g n . a n d acute 1' c e ll (IF N -d e ltn . T N F ) . iiin c ro p ln g i-. (I L - l. T N K -alpba.
p h a s e p ro c e s se s IL -I2 ) a n d c y to k in e s
in fla m m a tio n & n e c r o s is 246

In r e s p o n s e to a n in ju ry , c a p illa r y p e r m e a b ility in c r e a s e s r e s u lt in g in
th e fo r m a tio n of:

• p la s m a
• s e ru m

• e x u d a te
• tr a n s u d a t e

M IC R O B IO L O G Y /P A T H O L O G Y i t d e n t a l decks
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • e xu d ate
*** T h e e d e m a r e s u ltin g fr o m in fla m m a tio n is c a u s e d by in c r e a s e d c a p illa r y
p e r m e a b ility .
T h e e d e m a flu id is c a lle d a n exu d a te ( c o m m o n ly c a lle d "p u s "). T h e e a s ie s t w a y to
s e e e x u d a te is to p u n c tu r e a b lis te r, th e flu id th a t e s c a p e s is e x u d a te . If th e flu id is
c lo u d y o r d is c o lo r e d it is a s tr o n g in d ic a tio n o f th e p r e s e n c e o f a n in fe c tio n in th e
w o u n d . E x u d a te is c h a r a c te r iz e d b y b e in g p ro te in -ric h , c e ll-ric h , g lu c o s e -p o o r
an d h av in g a high s p e c ific g ra v ity ( g r e a te r th a n 1 .0 2 ). T y p e s o f in fla m m a to r y
e x u d a te s in c lu d e : s u p p u r a tiv e , p u r u le n t, fib r in o u s , a n d p s e u d o -m e m b ra n o u s .
In a d d itio n to w a te r , e x u d a te c o n ta in s v a r y in g a m o u n ts o f n u trie n ts , o x y g e n ,
a n tib o d ie s a n d w h ite b lo o d c e lls ( n e u tr o p h ils ) . T h e firs t role o f e x u d a te is to flu sh
a w a y a n y fo r e ig n m a te r ia l fro m th e s ite o f th e in ju ry . It a ls o a c ts a s th e ca rrier
m e d iu m to b rin g fib rin a n d o th e r r e p a ir m a te r ia ls to th e s ite o f th e in ju ry . L a te r in th e
in fla m m a to r y r e s p o n s e it a c ts a s th e c a r r ie r fo r le u k o cy tes ( p r in c ip a lly P M N 's ) a n d
m o n o c y te s a n d s u p p lie s th e m w ith o x y g en a n d n u trie n ts w h ile th e y in g e s t
b a c te r ia a n d o th e r d e b r is in th e w o u n d . T h e p r e s e n c e o f e x u d a te a ls o e n ab le s th e
m o v e m e n t o f th e s e p h a g o c y tic c e lls w ith in th e w o u n d . L a te r in th e h ealin g p ro cess
th e n u tr ie n ts in th e e x u d a te a re u s e d b y th e n e w tis s u e to h e lp in th e g e n e r a tio n of
g ra n u la tio n tis s u e . F in a lly th e e x u d a te acts a lu b ric a n t s p e e d in g u p th e m ig r a tio n o f
e p ith e lia l c e lls a c r o s s th e w o u n d s u rfa c e to c o m p le te th e in itia l r e p a ir o f th e w o u n d .
T ra n su d a tes r e s u lt fro m in c r e a s e d in tr a v a s c u la r h y d r o s ta tic p re s s u r e o r fro m a lte re d
o s m o tic p r e s s u r e . T h is flu id is th in a n d w a te r y a n d is c h a r a c te riz e d b y fe w b lo o d
ce lls , lo w p ro tein c o n te n t, an d a lo w s p e c ific g ra v ity (le s s th a n 1 .0 1 2 ). It is
p r e s e n t in n o n -in fla m m a to ry c o n d itio n s .
1. G e n e r a lly m o s t o f th e c o m m o n ac u te in fla m m a to r y r e a c tio n s c o n ta in
la rg e a m o u n ts o f n e u tro p h ils a n d a re te rm e d s u p p u ra tiv e ( m e a n in g to
p r o d u c e p u ru le n t m a tte r).
2. T h is s u p p u r a tio n is th e re s u lt o f tis s u e n e c ro s is , p r o te o ly tic e n z y m e s ,
W B C s , a n d a b u ild u p o f tis s u e flu id .
in fla m m a tio n & n e c ro s is 247

A c u te in fla m m a tio n is a n e a r ly d e fe n s e m e c h a n is m to c o n ta in an
in fe c tio n , p r e v e n t its s p r e a d fr o m th e in itia l fo c u s a n d s ig n a l
s u b s e q u e n t s p e c ific im m u n e r e c e p to rs .
T is s u e d a m a g e is c a u s e d to s o m e e x te n d b y c o m p le m e n t a n d
m a c r o p h a g e s b u t m o s tly b y n e u tr o p h ils .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • both statem en ts are true
A cu te inflam m atio n is an e a rly d e fe n s e m e c h a n is m to c o n ta in an in fe c tio n , p re v e n t its
sp re a d fro m th e in itia l fo c u s an d s ig n a l s u b s e q u e n t s p e c ific im m u n e re c e p to rs . T h e three
m ajor events in a c u te in fla m m a tio n are (1) exp an sio n o f cap illaries to in c re a s e blo o d
flo w (c a u s in g re d n e s s o r rash an d re le a s in g heat); (2) increase in p erm eab ility of the
m ic ro v a s c u la tu re s tru c tu re to a llo w e s c a p e o f flu id , p la s m a p ro te in s , an d le u k o c y te s from
th e c irc u la tio n (s w e llin g o r e d e m a ); an d (3) re c ru itm e n t of n eu tro p h ils a n d th e ir
a c c u m u la tio n an d re s p o n s e to in fe c tio n at th e s ite o f injury.
In fla m m a to ry re s p o n s e s are b e n e fic ia l b u t a re a lso a ss o c ia te d w ith pain, re d n e ss, heat,
s w e llin g , an d can a ls o c a u s e tis s u e d a m a g e . T is s u e d a m a g e is c a u s e d to s o m e e x te n t by
c o m p le m e n t a n d m a c ro p h a g e s b u t m o s tly by n eu tro p h ils. D ead n e u tro p h ils a re a m a jo r
c o m p o n e n t o f pus. K in in s a n d c lo ttin g fa c to rs in d u c e d by tis s u e d a m a g e (e.g., fa c to r XII
[H a g e m a n fa c to r], b ra d y k in in , fib rin o p e p tid e s ) are a lso in v o lv e d in in fla m m a tio n . T h e s e
fa c to rs increase vascu lar p erm eab ility a n d are ch em o tactic for leukocytes.
P ro d u cts o f a ra c h id o n ic a cid m e ta b o lism a lso a ffe ct in fla m m a tio n . C yclo o xyg e n a se -2 _ (C o x-
2) and 5 -lip o x y g e n a s e c o n v e rt a ra c h id o n ic acid to p ro sta g lan d in s an d leu ko trienes,
re s p e c tiv e ly , w h ic h can m e d ia te e s s e n tia lly e v e ry a s p e c t of a c u te in fla m m a tio n . T h e
co u rs e of in fla m m a tio n can be fo llo w e d by rapid in c re a s e s in a c u te p h a s e p ro te in s,
e s p e c ia lly C -reactive pro tein (w hich can in c re a s e a th o u s a n d fo ld w ith in 24 to 4 8 hours)
a n d seru m am ylo id A.

Im portant: Leukocytes (p re d o m in a te ly p o lym o rp h o n u clea r n eu tro p h ils) are th e first

d e fe n s e c e ll to m ig ra te to th e in ju re d tis s u e by c h e m o ta x is . T h e s e le u k o c y te s e n g u lf
p a rtic u la te m a tte r by p h a g o c y to s is . T h is e n g u lfe d m a tte r b e c o m e s a p h ag o so m e an d
th e n c o m b in e s w ith ly s o s o m a l g ra n u le s to form a p h ag o lyso so m e, in w h ic h d ig e s tio n of
th e e n g u lfe d p a rtic le o ccu rs.
C e lls in vo lve d in acu te in fla m m a tio n in c lu d e :
• B a s o p h ils , tis s u e m a s t c e lls, an d p la te le ts are im p o rta n t in th e vascu lar p h a se
• P M N 's p re d o m in a te in th e cellular p h a se
• M acro p h ag es a p p e a r late in the c e llula r ph ase an d re p re s e n t a tra n s itio n b e tw e e n
a c u te a nd c h ro n ic in fla m m a tio n
Note: E o s in o p hils a re th e p re d o m in a n t in fla m m a to ry c e lls in allerg ic reaction s a nd
p arasitic infections.
s y n d ro m e s 248

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith b io tin .

• a ta x ia
• b e r ib e r i

• s e b o r r h e ic d e r m a titis
• n e r v o u s d is o r d e r s
• a n e m ia
• sc u rvy
• c a n b e in d u c e d b y a v id in

M IC R O B IO L O G Y /P A T H O L O G Y 1 * d e n ta ld ec ks
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • seborrheic derm atitis
• nervous d isorders
can be induced by avidin
V ita m in s

V ita m i n F u n c tio n S ig n * o f D eficien c y

A P a il o f ih o d o p sm a N ig h t b lin d n e s s (re tin a l)

• G ro w th te ta rd a lio n (re tin o ic a cid )

D • (»! trac t: O n '* a t n o ip tio n • R ick e ts , oste o m a lac ia

• B o n e s u p p o rt* P T H

E • A n tio x id a n t a A ta x ia

K • A ctiv atio n o f p ro th ro m b in a B le e d in g d is o rd e r (U. V U. IX . X)

• S y n th es is o f g a m m a - c arix ix y gln la m a le

C • Ily d io x yla tK 'n o f p r a lin e & lys ine • S c tt n 7

B ! (th ia m in) • D ec arb o x y la tio n s # B e riberi

B 2 (rib o fla v in ) • F la vins (FM N e t c ) a G lo s s itis , c he ilos is

B 6 (p y rid o x iu e) • T ta n sa u u n a lio n * • A n eu tia (m ic ro c y tic )

• D ea m ina tion * a N e u ro p a th y

B12 a M e th ion in e s yn th e sis a A n e m ia (n iac io c y tic )

• O d d ca rb o n fa tty acid a N e u ro p a th y
• D eg rad atio n • D . L alin tt (w o t tu in fe s ta tio n )

N iac in • N A D ’. N A D P " a P e llag ra (d ia rrh ea , d e m en tia, d e rm a titis)

P a u to lb e n a te a 0 o e n ry m e A a H ea d a c h e , tianxen

B iotin a C atbo x ylalio n * a S e b o rrh e ic d e tiu a lilis

a N erv o u s d is o rd e rs
• C a n h e in d u c e d b y a v id in (p ro te in in
ra w e g g w h ite ) w h ic h b in d s b iotin

F o lic ac id a O n e c arb o n m e tab o lism • A n em ia (m ac ro c y tic )

a G lo s s itis , c o litis

Rem em ber: M alabsorption c a n c a u s e d e fic ie n c ie s o f a ll n u tr ie n ts o r o f p ro te in s , fa ts ,

v ita m in s , o r m in e r a ls s e le c tiv e ly . T h e s y m p to m s v a r y d e p e n d in g o n th e s p e c ific
d e fic ie n c ie s . T h e a b s o r p tio n of th e fat-soluble v ita m in s (A , D, E, K) is a ffe c te d to th e
g r e a te s t e x te n t. V ita m in B 1 2 m a la b s o r p tio n o c c u r s in pernicious anem ia d u e to th e
a b s e n c e o f in tr in s ic fa c to r . T h is is c a u s e d b y th e d e s tr u c tio n o r m a lfu n c tio n o f g a s tric
p a rie ta l c e lls . Note: V ita m in B 1 2 m a la b s o r p tio n a ls o o c c u r s w ith C rohn's d isease.
s y n d ro m e s 249

W h ich m a la b s o rp tio n s y n d ro m e is c au s e d by a s e n s itiv ity to g lu ten in

c e re a l?

• t r o p ic a l s p r u e
• c e lia c d is e a s e
• w h ip p le d is e a s e
• a u to im m u n e e n te r o p a th y

MICROBIOLOGY/PATHOLOGY i^ d e n t a ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • celiac disease
M alab so rp tio n , w h ich p re s e n ts m ost c o m m o n ly a s c hron ic d iarrh ea, is c h a ra c te riz e d by
d e fe c tiv e a b s o rp tio n of fa ts, fa t- a nd w a te r-s o lu b le v ita m in s , p ro te in s, ca rb o h y d ra te s ,
e le c tro ly te s a n d m in e ra ls, a nd w a te r. C h ro n ic m alab so rp tion can be a c c o m p a n ie d by
w e ig h t loss, a n o re xia , a b d o m in a l d is te n tio n , b o rb o ry g m i, a nd m u s c le w a s tin g . A h a llm a rk
of m a la b s o rp tio n is steatorrhea, c h a ra c te riz e d by e x c e s s iv e fe ca l fa t a n d bulky, fro th y,
g reasy, y e llo w o r c la y -c o lo re d stools.

M alab so rp tive disorders:

• Celiac disease: is a c o n d itio n w h e re th e m u c o s a l lin in g o f th e sm a ll inte s tin e is
d a m a g e d by in g e s tio n of g lu te n . O n e fa c to r th o u g h t to p la y a role in w h e n a nd how
c e lia c a p p e a rs is w h e th e r a perso n w a s b re a s tfe d a n d ho w long. T h e lo n g e r a p erson
w a s b re a stfe d , th e la te r th e s y m p to m s of ce lia c d is e a s e app e a r, a nd th e m o re a typical
th e s y m p to m s . P e rso n s w ith th is d is e a s e have to a v o id all fo o d s th a t co n ta in g luten.
Note: It ca n be fa ta l in a d u lts due to th e d e v e lo p m e n t of ly m p h o m a in th e in te stin e .
• T ro p ical sprue: th e c a u s e of th is d is e a s e is u n kn o w n , b u t it m a y be re la te d to an
in fe c tio u s o rg a n is m . T h e c o n d itio n a ffe c ts re s id e n ts of o r v is ito rs to th e tro p ic s . T yp ica l
s y m p to m s in c lu d e s te a to rrh e a , diarrhea, w e ig h t loss, a nd a s o re to n g u e fro m vita m in
B d e fic ie n c y . T re a tm e n t c o n s is ts of a n tib io tic s , ofte n T e tra c y c lin e , fo r up to 6 m o n th s.
• W h ipp le disease: is a sy s te m ic b a c te ria l (Tropheryma whippelii) illn e s s u s u a lly
a ffe c tin g m id d le a g e m en a nd p re s e n ts d ia rrh e a , a n e m ia , a rth ritis , fever, w e ig h t loss,
s w o lle n lym p h no d e s a nd skin p ig m e n ta tio n . It is d ia g n o s e d b y ta k in g a s m a ll bo w e l
b io p s y th ro u g h an e n d o s c o p e , a nd th e tre a tm e n t is a n tib io tic s (p e n ic illin or
te tra c y c lin e ) fo r o ne y e a r o r longer.
• A u to im m u n e enteropathy: is an X -lin ke d d is o rd e r c h a ra c te riz e d by s e ve re p e rs is te n t
d ia rrh e a a nd a u to im m u n e d is e a s e th a t o c c u rs m o s t ofte n in yo u n g c h ild re n .
• A b etalip o p ro teinem ia: is a rare a u to so m a l re ce ssive d ise a se c h a ra c te riz e d by an
in a b ility to s e c re te trig ly c e rid e -ric h lip o p ro te in s . It is ca u s e d b y a m u ta tio n in the
m icro so m a l trig ly c e rid e s tra n s fe r p ro te in (M TP ) th a t c a ta ly z e s tra n s p o rt of trig ly c e rid e s ,
c h o le s te ro l e s te rs, a nd p h o s p h o lip id s .
• C rohn's disease: is a c h ro n ic in fla m m a to ry c o n d itio n th a t m ay a ffe c t any p a rt o f th e Gl
tra c t b u t has a p a rtic u la r te n d e n c y to a ffe c t th e te rm in a l ileum a n d a s c e n d in g colon.
T h e m a jo r s y m p to m s a re d ia rrh e a , a b d o m in a l pain a nd w e ig h t loss. C o n s titu tio n a l
s y m p to m s of m alaise, lethargy, a n o re xia , nau se a , v o m itin g a nd lo w -g ra d e fe v e r m ay
be p re s e n t.
s y n d ro m e s 250

W h ic h of th e fo llo w in g is c h a ra c te riz e d b y th e p re s e n c e o f n u m e ro u s
p o ly p s a lo n g w ith skin an d b o n e tu m o rs ?

• T u r c o t 's s y n d r o m e
• G a r d n e r 's s y n d r o m e
• P e u tz - J e g h e r s s y n d r o m e
• fa m ilia l a d e n o m a to u s p o ly p o s is

M ICRO BIOLOGY/PATHOLOGY i^ d e n t a ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • G a r d n e r 's s y n d r o m e
A G l p o ly p is d e f in e d a s a m a s s o f th e m u c o s a l s u r f a c e p r o t r u d in g in to th e
lu m e n o f th e b o w e l. G l p o ly p o s is is c h a r a c t e r iz e d b y m u ltip le p o ly p s w it h in th e
G l tr a c t.
A v a r ie ty o f p o ly p o s is s y n d ro m e s c a n a ff e c t th e Gl tr a c t:
• F a m ilia l a d e n o m a t o u s p o ly p o s is :
° C a u s e d b y t h e a b se n c e o f A P C ( a t u m o r s u p p r e s s o r g e n e )
» A u t o s o m a l d o m in a n t
o C h a r a c t e r iz e d b y th e p r e s e n c e o f n u m e r o u s a d e n o m a t o u s p o ly p s
° T h e r is k o f m a lig n a n t tr a n s f o r m a t io n a p p r o a c h e s 1 0 0 %
• G a rd n e r's s y n d ro m e :
° A u t o s o m a l d o m in a n t
o C h a r a c t e r iz e d b y th e p r e s e n c e o f n u m e r o u s a d e n o m a t o u s p o ly p s a lo n g
w it h skin an d b o n e tu m o rs . S u p e r n u m e r a r y te e th a r e c o m m o n .
» T h e r is k o f m a lig n a n t tr a n s f o r m a t io n a p p r o a c h e s 1 0 0 %
• T u rc o t's s y n d ro m e :
° A u t o s o m a l re c e s s iv e
» C h a r a c t e r iz e d b y a d e n o m a t o u s p o ly p s a lo n g w ith C N S ( b r a in ) tu m o rs
= T h e r is k o f m a lig n a n t t r a n s f o r m a t io n is h igh
• P e u tz -J e g h e rs s y n d ro m e :
» A u t o s o m a l d o m in a n t
° C h a r a c t e r iz e d b y h a m a r to m a to u s p o ly p s ( n o n - n e o p la s tic ) o f th e c o lo n
a n d s m a ll in t e s t in e ( e s p e c ia lly in th e je ju n u m )
o C h a r a c t e r iz e d b y m e la n in p ig m e n ta tio n in th e m o u th a n d o n th e lip s ,
h a n d s , a n d g e n it a lia
° T h e s e p o ly p s h a v e n o m a lig n a n t p o te n tia l t h e m s e lv e s
° H o w e v e r , t h is s y n d r o m e is a s s o c ia te d w it h in c re a s e d ris k fo r
a d e n o c a rc in o m a o f th e c o lo n , a n d m a lig n a n c y a t o t h e r s it e s , s u c h a s
th e s to m a c h , b r e a s t, lu n g , o r o v a r ie s
s y n d ro m e s 251

P a tie n ts w ith D o w n s y n d ro m e a re a t an in c re a s e d ris k for:

• o s te o s a r c o m a
• ly m p h o b la s tic le u k e m ia
• b e r r y a n e u r y s m o f th e c ir c le o f W illis
• F a b r y d is e a s e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n t a ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 ly m p h o b la s tic le u k e m ia
A b n o r m a litie s o f a u to s o m a l c h r o m o s o m e s :
• D ow n s yn d ro m e:
° M o s t fr e q u e n tly o c c u rrin g c h r o m o s o m a l d is o rd e r; c a u s e d b y tris o m y 21;
in c id e n c e in c re a s e s w ith m a te rn a l age
C h ara c te ris tic s :
■ M e n ta l r e ta rd a tio n
■ L a rg e fo r e h e a d , b ro a d n a s a l b rid g e , w id e - s p a c e d e y e s , e p ic a n th a l fo ld s ,
la rg e p ro tru d in g to n g u e , h y p o d o n tia , a n d s m a ll lo w - s e t e a r s
■ S h o rt, b ro a d h a n d s w ith c u r v a tu r e of th e fifth fin g e r

C o m p lic a tio n s o f D o w n syn d ro m e:

■ C o n g e n ita l h e a rt d is e a se , w ith a tria l s e p ta l d e fe c t a s th e m o s t c o m m o n
■ In c re a s e d ris k o f ly m p h o b las tic le u ke m ia; in c re a s e d s u s c e p tib ility of
in fec tio n
■ W ith a d v a n c e d a g e ( o ld e r th a n 3 5 ), s h o w c lin ic a l s ig n s a n d s y m p to m s o f
A lz h e im e r's d is e a s e
• Cri du c h a t s y n d ro m e
° C a u s e d b y d e le tio n of th e s h o r t a rm o f c h r o m o s o m e 5; c h a r a c te r is tic s a re
s e v e r e m e n ta l r e ta rd a tio n , m ic ro c e p h a ly , a n d a n u n u s u a l c a tlik e c ry
• D iG e o rg e s y n d ro m e
* C a u s e d b y d e le tio n o f a p o rtio n o f c h r o m o s o m e 22
° C h a r a c te r is tic s in c lu d e : C A T C H 2 2 ( c a r d ia c a b n o r m a litie s , a b n o r m a l fa c ie s , T
c e ll d e fic ie n t b e c a u s e o f th y m ic h y p o p la s ia , c le ft p a la te , h y p o c a lc e m ia a n d
m ic r o d e le tio n o f 2 2 q 1 1)
• E d w a rd s s y n d ro m e (triso m y 18)
° C h a r a c te r is tic s in c lu d e m e n ta l r e ta rd a tio n , fa c e h a s a p in c h e d a p p e a ra n c e ,
m ic ro g n a th ia (s m a ll ja w ) , h e a d is s m a ll w ith lo w - s e t e a rs , a n d c o n g e n ita l h e a rt
d is e a s e
• P atau s y n d ro m e (tris o m y 13)
° C h a r a c te r is tic s in c lu d e m e n ta l r e ta rd a tio n , m ic r o c e p h a ly , m ic r o p h th a lm ia , c left
lip a n d p alate, b ra in a b n o r m a litie s , p o ly d a c ty ly , a n d c o n g e n ita l h e a rt d is e a s e
s y n d ro m e s 252

E ach o f th e fo llo w in g are s y m p to m s of S jo g re n 's s y n d ro m e E X C E P T

o n e. W h ich o n e is th e E X C E P T IO N ?

• x e r o s to m ia
• k e r a to c o n ju n c tiv itis s ic c a
• s a r c o id o s is
• a s s o c ia te d C T d is e a s e

M ICROBIOLOGY/PATHOLOGY i* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • s a rc o id o s is
S jo g r e n 's s y n d r o m e is a c o n d it io n t h a t is m o s t lik e ly o f a u t o im m u n e o r ig in . It is
m a r k e d c h ie f ly b y c h r o n ic in fla m m a tio n ( c a u s e d b y w h it e b lo o d c e ll in filt r a tio n )
o f th e s a liv a r y g la n d s a n d la c r im a l g la n d s . T h is u s u a lly p r o g r e s s e s t o f ib r o s is
a n d a t r o p h y o f th e s e g la n d s .
T h e triad o f fin d in g s f o u n d in S jo g r e n 's s y n d r o m e in c lu d e s :
• K e ra to c o n ju n c tiv itis s ic c a ( d r y e y e s )
• X e r o s to m ia ( d r y m o u th )
• A s s o c ia te d c o n n e c tiv e tis s u e d is e a s e ( m o s t o ft e n r h e u m a t o id a r th r itis )
A ll t h r e e s y m p t o m s ra re ly o c c u r in o n e p a tie n t. A d e f in it e d ia g n o s is c a n b e
m a d e o n ly w h e n at le a s t tw o o f th e s y m p t o m s a r e p r e s e n t. It is le s s c o m m o n
t h a n r h e u m a t o id a r t h r it is a n d m o re p re v a le n t in w o m e n t h a n in m e n .
■„ 1. T h e c lin ic a l p r e s e n ta tio n o f d im in is h e d la c r im a l a n d s a liv a r y g la n d
s e c r e tio n is o ft e n r e f e r r e d to a s s ic c a c o m p le x .
2 . S jo g r e n 's s y n d r o m e t h a t r e s u lts f r o m a r h e u m a t ic c o n d it io n is
c la s s ifie d a s s e c o n d a ry S jo g r e n 's s y n d r o m e . P rim a ry S jo g r e n 's
s y n d r o m e o c c u r s b y it s e lf.
3 . S jo g r e n 's s y n d r o m e is a s s o c ia t e d w it h a n in c r e a s e d in c id e n c e o f
m a lig n a n t ly m p h o m a .
4 . O c c a s io n a lly , th e ly m p h o c y t ic in filtr a tio n is m a s s iv e a n d c a u s e s
e n la r g e m e n t o f th e g la n d s ( th is is c a lle d M ik u lic z 's s y n d r o m e ) .
5 . T h e d e c r e a s e in s a liv a tio n m a y c a u s e ra m p a n t c a r ie s r e m in is c e n t
o f r a d ia tio n c a r ie s . T h is is a r e s u lt o f a s h ift t o w a r d a m o re
a c id o g e n ic m ic ro flo ra .
6. S S -A ( a n ti R o ) a n d S S -B ( a n ti L a ) a n tib o d ie s , w h ic h a r e d ir e c te d
a g a in s t tw o e x t r a c t a b le n u c le a r a n tig e n s , h a v e b e e n d e t e c t e d w it h
h ig h f r e q u e n c y in p a t ie n t s w it h S jo g r e n 's s y n d r o m e .
s y n d ro m e s 253

C h v o s te k 's s ig n a n d T r o u s s e a u 's s ig n a r e r e lia b le in d ic a to r s of:

• B e ll's p a ls y
• b o tu lis m
• r ic k e t s
• t e ta n y

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • te ta n y
T e ta n y is a c lin ic a l n e u ro lo g ic a l s y n d ro m e c h a r a c te r iz e d b y m u s c le tw itc h e s ,
c r a m p s , a n d c a r p o p e d a l s p a s m . W h e n s e v e r e , la r y n g o s p a s m a n d s e iz u r e s d e v e lo p .
A ll o f th e s e s ig n s a n d s y m p to m s r e fle c t irr ita b ility o f th e c e n tra l a n d p e r ip h e r a l
n e rvo u s s y s te m s . It is u s u a lly a s s o c ia te d w ith c a lc iu m d e fic ie n c y
( h y p o p a r a th y r o id is m ) , v ita m in D d e fic ie n c y o r a lk a lo s is . N ote: A c u te h y p o ca lc e m ia
in th e h u m a n b e in g o r d in a r ily c a u s e s n o o th e r s ig n ific a n t e ffe c ts b e s id e s te ta n y
b e c a u se te ta n y kills th e p a tie n t b e fo r e o th e r e ffe c ts c a n d e v e lo p .
T etan u s:
• T o x in e n te r s th e C N S a lo n g th e p e r ip h e r a l n e r v e s
• In c u b a tio n p e rio d o f 5 to 10 d a y s
• S tiffn e s s o f th e ja w s , d iffic u lty s w a llo w in g , fe v e r , h e a d a c h e
• R isu s s a rd o n ic u s : fix e d “ s m ile ” a n d e le v a te d e y e b r o w s
• S e v e r e s p a s m s o f th e n e c k , b a c k a n d a b d o m in a l m u s c le s
B o tu lis m :
• C. Botulinum s p o r e s a re h ig h ly r e s is ta n t to h e a t, b u t to x in s a re not
• P r o p e r c a n n in g a n d h e a tin g o f fo o d p re v e n ts b o tu lis m
• N a u s e a , v o m itin g a n d a b d o m in a l c r a m p s u s u a lly p r e c e d e th e n e u r o lo g ic a l
s y m p to m s : d r y m o u th , d ip lo p ia , lo s s o f p u p illa r y r e fle x e s , fo llo w e d b y d e s c e n d in g
p a r a ly s is a n d r e s p ira to r y fa ilu r e
_ 1. T e ta n y n o r m a lly w ill o c c u r w h e n th e b lo o d c o n c e n tr a tio n o f c a lc iu m
r e a c h e s a p p r o x im a te ly 6 m g % (n o rm a l is a b o u t 10 m g % ). It is le th a l a t
about 4 m g% .
2. C h v o ste k 's sig n : to c h e c k fo r C h v o s te k 's s ig n , ta p th e fa c ia l n e rv e
a b o v e th e m a n d ib u la r a n g le , a d ja c e n t to th e e a r lo b e . A fa c ia l m u s c le
s p a s m th a t c a u s e s th e p a tie n t's u p p e r lip to tw itc h , c o n fir m s te ta n y .
3. T ro u s s e a u 's s ig n : to c h e c k fo r T r o u s s e a 's s ig n , a p p ly a b lo o d p r e s s u r e
c u ff to th e p a tie n t's a rm . A c a r p o p e d a l s p a s m th a t c a u s e s th u m b
a d d u c tio n a n d p h a la n g e a l e x te n s io n , c o n firm s te ta n y .
s y n d ro m e s 254

D iG e o r g e s y n d r o m e a d v e r s e ly a ffe c ts th e d e v e lo p m e n t o f th e 3 rd a n d
4 th p h a r y n g e a l p o u c h e s . T h e r e s u lt o n th e im m u n e s y s te m w ill m o s t
lik e ly b e a d e fic ie n c y in:

• B c e lls
• T c e lls
• c o m p le m e n t
• in n a te im m u n ity

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • T c e lls
D iG e o r g e s y n d r o m e is a r a r e im m u n o d e f ic ie n c y d is o r d e r c h a r a c t e r iz e d b y
v a r io u s c o n g e n ita l a b n o r m a lit ie s t h a t d e v e lo p b e c a u s e o f d e fe c ts t h a t o c c u r
d u r in g e a r ly f e ta l d e v e lo p m e n t. T h e s e d e fe c ts o c c u r in a r e a s k n o w n a s t h e 3 rd
a n d 4 th p h a r y n g e a l p o u c h e s , w h ic h la te r d e v e lo p in to t h e t h y m u s a n d
p a r a th y r o id g la n d s . D e v e lo p m e n ta l a b n o r m a lit ie s m a y a ls o o c c u r in t h e 4 th
b r a n c h ia l a rc h .
N o r m a lly t h e t h y m u s g la n d is lo c a te d m id lin e in t h e u p p e r p a r t o f t h e c h e s t
c a v it y . It lie s b e lo w t h e s te r n u m a n d a b o v e th e t r a c h e a a n d th e h e a r t. In a
b a b y , t h e t h y m u s is r e la tiv e ly la r g e ( a s c o m p a r e d to th e r e s t o f t h e b a b y 's
b o d y ) . It t h e n c o n t in u e s to g r o w u n til p u b e r t y a t t h e e n d o f w h ic h it b e g in s to
s h r in k ( in v o lu te ) . It is t h e p r im a iy g la n d o f t h e ly m p h a t ic s y s te m , w h ic h is
n e c e s s a r y f o r t h e n o r m a l f u n c t io n in g o f t h e im m u n e s y s te m . T h e p a r a th y r o id
g la n d s , lo c a te d o n t h e s id e s o f t h e t h y r o id g la n d , a r e r e s p o n s ib le f o r th e
m a in t e n a n c e o f n o r m a l le v e ls o f c a lc iu m in t h e b lo o d . T h e t h y m u s a n d
p a r a t h y r o id g la n d s a r e m is s in g o r u n d e r d e v e lo p e d in c h ild r e n w it h D iG e o r g e
s y n d r o m e . T h e s y m p t o m s o f t h is d is o r d e r v a r y g r e a tly , d e p e n d in g u p o n th e
e x t e n t o f t h e m is s in g t h y m u s a n d p a r a t h y r o id tis s u e . T h e p r im a r y p r o b le m
c a u s e d b y D iG e o r g e s y n d r o m e is th e r e p e a te d o c c u r r e n c e o f v a r io u s
in fe c tio n s d u e t o a d im in is h e d im m u n e s y s te m .
1. T h e a b s e n c e o f th e t h y m u s r e s u lts in T c e ll d e f ic ie n c y . T h e s e
c h ild r e n h a v e n o r m a l B ly m p h o c y te s a n d fo r m a n t ib o d ie s , b u t
th e y h a v e d e c r e a s e d o r a b s e n t d e la y e d - ty p e h y p e r s e n s itiv ity .
2 . T h e s e c h ild r e n d e v e lo p te t a n y d u e t o h y p o c a lc e m ia ( f r o m th e
a b s e n c e o f t h e p a r a th y r o id s ) .
3 . U p t o 7 5 % o f m y a s t h e n ia g r a v is p a t ie n t s p r e s e n t w it h a n a b n o r m a l
t h y m u s s u c h a s a t h y m o m a ( a t u m o r o f th e th y m u s ) .
s y n d ro m e s 255

W h ic h im m u n o d e fic ie n c y d is o r d e r fe a tu r e s in c o m p e te n t o r a b s e n t T
c e lls a n d B c e lls ?

• W is k o tt - A ld r ic h s y n d r o m e
• s e v e r e c o m b in e d im m u n o d e fic ie n c y d is e a s e
• a ta x ia - te la n g ie c t a s ia
• h y p e r - lg E s y n d r o m e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • s e v e r e c o m b in e d im m u n o d e f ic ie n c y d is e a s e
T h e m o s t d a n g e r o u s t y p e o f c o n g e n it a l ( in h e r ite d ) im m u n o d e f ic ie n c y , s e v e r e
c o m b in e d im m u n o d e f ic ie n c y d is e a s e ( S C ID ) , r e s u lt s f r o m a f a ilu r e o f s te m
c e lls t o d if f e r e n t ia t e p r o p e r ly . I n d iv id u a ls w it h S C ID h a v e n e it h e r B - n o r T -
ly m p h o c y t e s a n d a r e in c a p a b le o f a n y im m u n o lo g ic a l r e s p o n s e . T h e s e
c h ild r e n g e n e r a lly d ie b e fo r e a g e tw o .
N o te : S C ID b e c a m e m o r e w id e ly k n o w n in th e 1 9 7 0 s w h e n th e w o r ld le a r n e d
o f D a v id V e tt e r , a b o y w ith S C ID w h o liv e d f o r 1 2 y e a r s in a p la s t ic , g e r m - fr e e
b u b b le .
T h e W is k o tt-A ld r ic h s y n d r o m e ( a ls o c a lle d im m u n o d e f ic ie n c y w it h e c z e m a
a n d th r o m b o c y t o p e n ia ) a ff e c t s o n ly b o y s a n d is c h a r a c t e r iz e d b y d e f e c t iv e B
c e ll a n d T c e ll fu n c tio n s . Its c lin ic a l f e a t u r e s in c lu d e t h r o m b o c y t o p e n ia w it h
s e v e r e b le e d in g , e c z e m a , r e c u r r e n t in fe c tio n , a n d a n in c r e a s e d r is k o f
ly m p h o id c a n c e r s .
A ta x ia - t e la n g ie c t a s ia is a n in h e r ite d d is o r d e r t h a t a f fe c ts m a n y t is s u e s a n d
s y s t e m s in th e b o d y . M u lt ip le s y m p t o m s m a y in c lu d e t e la n g ie c t a s is ( d ila tio n o f
c a p illa r ie s ) , a t a x ic ( u n c o o r d in a te d ) g a it, p r o n e n e s s t o in fe c tio n , d e f e c t iv e
h u m o r a l a n d c e llu la r im m u n it y a n d in c r e a s e d r is k o f m a lig n a n c ie s . T h e m o s t
o b v io u s s y m p t o m s o f t h e d is e a s e a r e m u ltip le te la n g ie c t a s is th a t a r e e a s ily
v is ib le in th e w h it e o f th e e y e a n d s k in a r e a s s u c h a s th e e a r a n d n o s e a lo n g
w ith g r a y in g o f th e h a ir , a n d ir r e g u la r p ig m e n t a t io n o f th e a r e a s e x p o s e d to
s u n lig h t. In a d d it io n , th e r e is d e c r e a s e d c o o r d in a t io n o f m o v e m e n t s ( a ta x ia ) in
la te c h ild h o o d .
H y p e r im m u n o g lo b u lin E s y n d r o m e ( a ls o k n o w n a s J o b s y n d r o m e ) is a n
im m u n o d e f ic ie n c y d is o r d e r c h a r a c t e r iz e d b y v e r y h ig h le v e ls o f Ig E a n tib o d ie s
and re p e a te d in fe c tio n s , m o s t c o m m o n ly by Staphylococcus aureus.
T r e a t m e n t c o n s is t s o f t a k in g a n t ib io t ic s c o n t in u a lly f o r t h e in fe c tio n s .
s y n d ro m e s 256

F ro m th e fo llo w in g lis t s e le c t th e T H R E E ite m s a s s o c ia te d w ith

K lin e fe lt e r 's s y n d r o m e .

• e x t r a c h r o m o s o m e 21
•XO
• XXY
• e x tr a c h r o m o s o m e 1 8
• a ff e c ts 1 in 5 0 0 m e n
• a ff e c ts w o m e n
• h y p e r g o n a d is m
• h y p o g o n a d is m

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • XXY
• a f f e c t s 1 in 5 0 0 m e n
• h y p o g o n a d is m
K lin e fe lte r s y n d r o m e is a c h r o m o s o m e a b n o r m a lit y t h a t a f fe c ts o n ly m e n
a n d c a u s e s h y p o g o n a d is m . A p e r s o n 's s e x is d e t e r m in e d b y th e X a n d Y
c h r o m o s o m e s . N o r m a lly , m e n h a v e a n X a n d a Y a n d w o m e n h a v e tw o X 's . In
K lin e f e lt e r s y n d r o m e , a m a le h a s t w o X 's a n d a Y .
T h e c o n d it io n is c o m m o n a n d a f f e c t s 1 in 5 0 0 m e n . T h e in f a n t a p p e a r s n o r m a l
a t b ir th , b u t th e d e f e c t u s u a lly b e c o m e s a p p a r e n t in p u b e r t y w h e n s e c o n d a r y
s e x u a l c h a r a c t e r is t ic s fa il t o d e v e lo p ( o r d e v e lo p la te ) . T h e s e in d iv id u a ls h a v e
s m a ll te s t e s , e n la r g e d b r e a s ts , a f e m in in e d is t r ib u t io n o f p u b ic h a ir , a n d
f r e q u e n t ly m ild r e ta r d a tio n . T h e s e b o y s te n d to b e ta ll, w it h lo n g le g s . T h is
d is o r d e r is a s s o c ia t e d w ith a d v a n c e d m a te r n a l a n d p a te r n a l a g e .
T u r n e r s y n d r o m e is a b ir th d e f e c t c a u s e d b y th e a b s e n c e o r d e f e c t o f a n X
c h ro m o s o m e , w h ic h in h ib its sexual d e v e lo p m e n t a n d u s u a lly causes
in fe r tility . T h e in c id e n c e is 1 o u t o f 3 , 0 0 0 liv e b ir th s . G ir ls w it h T u r n e r 's
s y n d r o m e u s u a lly h a v e s h o r t s ta tu r e , w e b b in g o f th e s k in o f th e n e c k , a b s e n t
o r r e ta r d e d d e v e lo p m e n t o f s e c o n d a r y s e x u a l c h a r a c t e r is t ic s a t p u b e r t y ,
absence of m e n s tr u a tio n , c o a r c t a t io n ( n a r r o w in g ) of th e a o rta and
a b n o r m a lit ie s o f th e e y e s a n d b o n e s . T h e c o n d it io n is e it h e r d ia g n o s e d a t b ir th
b e c a u s e o f th e a s s o c ia t e d a n o m a lie s , o r a t p u b e r t y w h e n th e r e is a b s e n t o r
d e la y e d m e n s e s a n d d e la y e d d e v e lo p m e n t o f n o r m a l s e c o n d a r y s e x u a l
c h a r a c t e r is t ic s .
E x a m p le s o f d is e a s e s t h a t c a n b e d ia g n o s e d b y k a r y o ty p in g :
• K lin e fe lte r 's s y n d r o m e : X X Y
• T r is o m y 1 8 : e x tr a c h r o m o s o m e 1 8
• D o w n 's s y n d r o m e : e x t r a c h r o m o s o m e 21
• T u r n e r 's s y n d r o m e : X O
s y n d ro m e s 257

X -lin k e d a g a m m a g lo b u lin e m ia is c h a r a c te r iz e d b y th e fa ilu r e o f T c e ll

p r e c u r s o r s to d e v e lo p in to m a tu r e T c e lls .
T h e d is e a s e u s u a lly d o e s n o t b e c o m e a p p a r e n t u n til a b o u t 6 m o n th s
o f a g e , a s m a te r n a l im m u n o g lo b u lin s a r e d e p le te d .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e fir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e f ir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e
X - lin k e d a g a m m a g lo b u lin e m ia ( B r u t o n 's a g a m m a g lo b u lin e m ia ) is o n e o f
th e m o r e c o m m o n f o r m s o f p r im a r y im m u n o d e f ic ie n c y . It is c h a r a c t e r iz e d b y
th e fa ilu r e o f B c e ll p r e c u r s o r s ( p r o - B c e lls a n d p r e - B c e lls ) to d e v e lo p in to
m a tu r e B c e lls . X - lin k e d a g a m m a g lo b u lin e m ia is c a u s e d b y m u t a t io n s in a
c y t o p la s m ic ty r o s in e k in a s e , c a lle d B r u to n ty r o s in e k in a s e . T h e g e n e t h a t
e n c o d e s it is lo c a te d o n th e lo n g a r m o f th e X c h r o m o s o m e .
A s a n X - lin k e d d is e a s e , t h is d is o r d e r is s e e n a lm o s t e n t ir e ly in m a le s . T h e
d is e a s e u s u a lly d o e s n o t b e c o m e a p p a r e n t u n til a b o u t 6 m o n th s o f a g e , a s
m a t e r n a l im m u n o g lo b u lin s a r e d e p le t e d . In m o s t c a s e s , r e c u r r e n t b a c te r ia l
in f e c t io n s o f t h e r e s p ir a t o r y tr a c t, s u c h a s a c u t e a n d c h r o n ic p h a r y n g itis ,
s in u s itis , o t it is m e d ia , b r o n c h itis , a n d p n e u m o n ia , c a ll a tt e n t io n t o th e
u n d e r ly in g im m u n e d e fe c t. A lm o s t a lw a y s th e c a u s a t iv e o r g a n is m s a r e
H a e m o p h ilu s in flu e n z a e , S tre p to c o c c u s p n e u m o n ia e , or
S ta p h y lo c o c c u s a u re u s . N o te : T h e s e o r g a n is m s a r e n o r m a lly o p s o n iz e d b y
a n t ib o d ie s a n d c le a r e d b y p h a g o c y to s is .
I n d iv id u a ls w it h t h is d is e a s e a r e a ls o s u s c e p t ib le to c e r ta in v ir a l in fe c t io n s ,
e s p e c ia lly t h o s e c a u s e d b y e n te r o v ir u s e s , s u c h a s e c h o v ir u s , p o lio v ir u s , a n d
c o x s a c k ie v ir u s .
T h e c la s s ic f o r m o f t h is d is e a s e h a s th e fo llo w in g c h a r a c te r is tic s :
• B c e lls a r e a b s e n t o r m a r k e d ly d e c r e a s e d in th e c ir c u la tio n , a n d s e r u m
le v e ls o f a ll c la s s e s o f im m u n o g lo b u lin s a r e d e p r e s s e d
• G e r m in a l c e n t e r s o f ly m p h n o d e s , P e y e r 's p a tc h e s , th e a p p e n d ix , a n d
t o n s ils a r e u n d e r d e v e lo p e d
• P la s m a c e lls a r e a b s e n t t h r o u g h o u t th e b o d y
• T c e ll- m e d ia t e d r e a c tio n s a r e n o r m a l
h e m o d y n a m ic d y s fu n c tio n 258

R ig h t-s id e d h e a r t fa ilu r e re s u lts in:

• p u lm o n a r y e d e m a
• p e r ip h e r a l e d e m a
• ly m p h e d e m a
• c ir r h o s is o f th e liv e r

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • p e rip h e ra l e de m a
E d em a is a n a b n o r m a l a c c u m u la tio n o f flu id in th e in t e r s titia l s p a c e s o r b o d y c a v itie s .
C auses o f e d e m a :
• In c rea s e d c a p illa ry p e rm e a b ility ( p r in c ip a l fa c t o r ) : o c c u r s in in fla m m a tio n o r w ith
in ju r y to c a p illa r y e n d o th e liu m
• Increased hydrostatic pressure: is e x e m p lifie d b y c o n g e s tiv e h e a rt fa ilu r e
° R ig h t-s id ed h e a rt fa ilu r e r e s u lts in p e rip h e ra l e de m a
- L e ft-s id e d h e a r t fa ilu r e r e s u lts in p u lm o n a ry ed e m a
• D e c re a s e d o n c o tic p re s s u re : is fr o m h y p o a lb u m in e m ia , w h ic h r e s u lt s fr o m :
° In c r e a s e d lo s s o f p r o te in ( s e e n in n e p h r o t ic s y n d r o m e )
° D e c r e a s e d p r o d u c tio n o f a lb u m in ( s e e n in c ir r h o s is o f th e liv e r )
• In c re a s e d s o d iu m reten tio n
• B lo ck ag e o f lym p h atics: r e s u lts in lym p h ed em a
T yp es o f e d e m a :
• A n a sa rc a: g e n e r a liz e d e d e m a
• H yd ro th orax : is a n a c c u m u la tio n o f flu id in th e p le u ra l c a v ity
• H yd ro cep h aly: is a n a c c u m u la tio n o f c e r e b r o s p in a l flu id in th e c ra n ia l c a v ity
• H yd ro p e rica rd iu m : is a n a c c u m u la tio n o f flu id in th e p e ric a rd ia l c a v ity
• H y d ro p e rito n e u m ( a s c ite s ) : is a n a c c u m u la tio n o f flu id in th e p e rito n e a l c a v ity
• T ra n s u d a te: n o n in fla m m a t o r y e d e m a flu id th a t r e s u lts fr o m a lt e r e d in t r a v a s c u la r
h y d r o s ta tic o r o s m o tic p r e s s u r e . It h a s a lo w p r o te in c o n t e n t a n d a s p e c ific g r a v ity
o f le s s th a n 1 .0 1 2
• E xu d ate: e d e m a flu id r e s u ltin g fr o m in c r e a s e d v a s c u la r p e r m e a b ility c a u s e d b y
in flam m atio n . It h a s a h ig h p r o te in c o n te n t a n d a s p e c ific g r a v ity e x c e e d in g 1 .0 2
E d e m a m a y b e g e n e ra lly d e s c rib e d in o n e o f tw o w a y s :
1. P ittin g e d e m a : w h e n y o u p r e s s a s w o lle n a r e a f o r 5 s e c o n d s a n d th e n
q u ic k ly r e m o v e it, a n in d e n ta tio n is le f t t h a t fills s lo w ly . S e en in a c u te
d is ea s e .
2 . N o n -p ittin g e d e m a : w h e n y o u p r e s s a s w o lle n a r e a fo r 5 s e c o n d s a n d
th e n q u ic k ly r e m o v e it, n o in d e n ta tio n is le ft in th e s k in . S e en in c h ro n ic
d is ea s e .
h e m o d y n a m ic d y s fu n c tio n 259

W h ic h o f th e fo llo w in g ty p e s o f th r o m b i fo r m a s a r e s u lt o f d a m a g e to
th e v e n tr ic u la r e n d o c a r d iu m (u s u a lly le ft v e n tr ic le fo llo w in g
m y o c a r d ia l in fa r c t)?

• agonal
• w h it e
• re d
• fib r in
• m u ra l

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n ta ld e c l< S
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • m ural
A b lo o d c lo t w ith in an a rte r y is k n o w n a s a n arterial th rom b o sis. A r te ria l th r o m b o s is is
re s p o n s ib le fo r h e a rt a tta c k s , s tro k e s a n d p e r ip h e r a l v a s c u la r d is e a s e ( th r o m b o s is in leg
a rte rie s ). A r te ria l th r o m b o s is u s u a lly a ffe c ts in d iv id u a ls w h o a lr e a d y h a v e ath ero sclerosis,
o r n a rro w in g o f th e a rte rie s . A th e ro s c le r o s is c a u s e s th e w a lls o f th e a rte r ie s to “ fu r u p ” w ith
d e p o s its o f a th e ro m a , a p o r rid g e -lik e s u b s ta n c e .
A th rom b u s is a s o lid m a s s o f c lo tte d b lo o d th a t fo r m s w h e n a n a lte r a tio n in th e e p ith e lia l
lin in g c a u s e s p la te le t a g g re g a tio n a n d c o n s e q u e n t fib r in e n tr a p m e n t o f re d a n d w h ite
b lo o d c e lls a lo n g w ith a d d itio n a l p la te le ts . T h r o m b u s fo rm a tio n is m o re r a p id in a re a s
w h e re b lo o d flo w is s lo w e r, b e c a u s e c o n ta c t b e tw e e n p la te le ts in c r e a s e s a n d th ro m b in
a c c u m u la te s . T h r o m b u s fo rm a tio n is e n h a n c e d b y e n d o th e lia l in ju ry , a n a lte r a tio n in b lo o d
flo w , a n d h y p e rc o a g u la b ility o f th e b lo o d .
T y p e s o f th ro m b i:
• A go n a l th ro m b u s : fo r m s in th e h e a rt d u r in g th e p r o c e s s o f d y in g a fte r p ro lo n g e d h e a rt
fa ilu re .
• M ural th r o m b u s : fo rm s a s a r e s u lt o f d a m a g e to th e v e n tr ic u la r e n d o c a rd iu m ( u s u a lly
le ft v e n tr ic le , fo llo w in g m y o c a rd ia l in fa rc t). A m a jo r c o m p lic a tio n o f a m u ra l th ro m b u s is
a c e re b r a l e m b o lis m . It c o m p lic a te s m y o c a rd ia l in fa r c tio n , a tria l fib rilla tio n , a n d
a th e ro s c le r o s is o f th e a o rta .
• W h ite th r o m b u s : a th ro m b u s c o m p o s e d c h ie fly o f b loo d platelets.
• Red th ro m b u s : fo rm e d r a p id ly b y th e c o a g u la tio n o f s ta g n a tin g b lo o d , c o m p o s e d o f
red b loo d cells r a th e r th a n p la te le ts .
• F ibrin th ro m b u s : fo rm e d b y re p e a te d d e p o s its o f fib rin fr o m th e c irc u la tin g b lo o d . It
u s u a lly d o es not c o m p le te ly o c c lu d e th e v e s s e l.
^ 1. M o rp h o lo g ic ally, a n arterial th r o m b u s s h o w s a lte r n a tin g re d a n d w h ite
la m in a tio n s ( lin e s o f Z a h n ) . V en o u s th ro m b i a re m o re u n ifo rm ly re d ; th e lin e s
a re d is tin c t.
2. P h leb itis is th e in fla m m a tio n o f a v e in . C o n g estio n is th e a c c u m u la tio n o f
e x c e s s iv e b lo o d w ith in th e b lo o d v e s s e ls . T h ro m b o lys is is th e b re a k in g u p of
a b lo o d c lo t. S tre p to k in a s e is m o s t c o m m o n ly u s e d to d is s o lv e b lo o d c lo ts .
3. A n em b o lus is a b lo o d c lo t th a t m o v e s th ro u g h th e b lo o d s tre a m u n til it
lo d g e s in a n a r ro w e d v e s s e l a n d b lo c k s c irc u la tio n . M o s t e m b o li a re
th ro m b o e m b o li.
h e m o d y n a m ic d y s fu n c tio n 260

In tr a c e llu la r a n a e r o b ic g ly c o ly s is a n d a s u b s e q u e n t b u ild u p o f la c tic

a c id o c c u r in w h ic h s ta g e o f s h o c k ?

• n o n - p r o g r e s s iv e
• p r o g r e s s iv e
• ir r e v e r s ib le
• c a r d io g e n ic

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • p r o g r e s s iv e
S h o ck is co m p le x by its v e ry n atu re . T h e p a th o p h ysio lo g y o f sh o ck m a n y tim e s in vo lve s the
m u ltiple fa ilu re s o f o rg a n s and even d e a th . S h o c k a t its m o st b a sic level is th e la c k o f
e q u ilib r iu m b e tw e e n th e c e ll's n e e d f o r o x y g e n a n d th e b o d y 's in a b ility to p r o v id e th a t
c e llu la r o x y g e n . T h e b o d y 's re sp o n se to s h o c k u su a lly o c c u rs in s ta g e s. T h e s e s ta g e s are
in itia l, c o m p e n s a to ry , p r o g r e s s iv e , and r e fra c to ry . T h e e tio lo g y o f sh o c k c a n be cla s s ifie d in
th re e ca te g o rie s w ith o n e c a te g o ry h a ving th re e s e p a ra te su b c a te g o rie s . T h e th re e m ain
c a te g o rie s a re h y p o v o le m ic , c a r d io g e n ic , and d is t r ib u t iv e s h o c k . D istrib u tive s h o c k can be
fu rth e r d e lin e a te d a s se ptic, n e u ro g e n ic, a n d a n a p h y la c tic shock.
T he s ta g e s o f sh o ck:
• In itia l s ta g e : h ere th e c a rd ia c o u tp u t is s e e n to d e cre a se , c a u sin g an im p a irm e n t o f the
tis s u e p e rfu sio n . T h is a c tio n trip s th e ce ll to co n ve rt, b e ca u se o f la c k o f s u ffic ie n t o xyg e n ,
fro m a e ro b ic to a n a e ro b ic m e ta b o lism . T he m e ch a n is m o f a n a e ro b ic m e ta b o lis m c a u s e s a
s u d d e n in cre a se in w a s te p ro d u cts ca lle d la c tic a c id th a t fu rth e r in ju re s th e cells, w hich
ca u se s fu rth e r cell d e a th in a cyclica l fa s h io n . A fte r th e b o d y e n te rs th e initial sta ge , if the
p ro b le m is n o t so lve d th e n s h o c k w ill p ro g re ss to th e c o m p e n s a to ry stage.
• C o m p e n s a to r y s ta g e : w h e re th e b od y trie s to co m p e n s a te fo r th e la ck o f e q u ilib riu m . In this
sta ge th e b od y w ill a lte r its h e m o d y n a m ic fu n c tio n s to c o m p e n s a te fo r p o o r tis s u e p e rfusio n.
T he h e a rt rate w ill increa se , the ve ss e ls of th e body w ill begin c o n strictin g and th e b od y will
begin to retain so d iu m a n d w ater. A d d itio n a lly as th e s ta g e p ro g re sse s th e b lo od g lu cose
levels w ill b egin to rise a nd th e re sp ira to ry rate w ill incre a se (h yp e rve n tila tio n ) in an a tte m p t to
b lo w o ff th e e ffe cts o f la ctic a cid o sis w h ic h o ccu rre d in the initial s ta g e w h e n th e b od y
sw itch e d o v e r fro m a e ro b ic to a n a e ro b ic m e ta b o lis m . T h e s e ch a n g e s s e t the s ta g e fo r the
p ro g re s s iv e sta ge .
• P r o g r e s s iv e s ta g e : ch a ra c te riz e d b y th e b e g in n in g o f fa ilu re o f th e c o m p e n s a to ry s ta g e to
bring th e b od y back to e q u ilibrium . T he fa ilu re o f th e c o m p e n s a to ry s ta g e s ig n a ls the
b eg in n in g o f th e sh o ck cycle b eing p e rp e tu a te d . B a sically, th e c ycle b e g in s to se lf-p e rp e tu a te
a d ow n w a rd spiral w h ich can end in dea th. D uring th is sta ge th e ce lls a re fu n ctio n in g on
a n a e ro b ic m e ta b o lism w h ic h is c a u sin g a b u ildu p o f la ctic a cid . A n a e ro b ic m e ta b o lism d oe s
not p ro d u ce e no ug h e ne rg y to s u stain c e llu la r life a nd c e lls b egin to die.
• R e fr a c to r y s ta g e : w h e re th e patie nt w ill reach a point o f no return. T his point is w h e re no
h e roic m e a s u re s w ill sa ve th e patient. T h is is b e c a u s e e v e ry o rg a n n e e d s its b a sic building
block, th e cell, to su rvive . If the ce lls o f an org an d ie th e n th e o rg a n d ie s. O n ce o n e o f the
org an s d ies th en o the rs w ill fo llo w su it and m ultiple o rg an fa ilu re w ill o ccu r e nding in death.
h e m o d y n a m ic d y s fu n c tio n 261

T h e m o s t c o m m o n ty p e o f s h o c k is:

• c a r d io g e n ic
• s e p tic
• n e u r o g e n ic
• h y p o v o le m ic

M IC R O B IO L O G Y /P A T H O L O G Y d ^ d e n ta ld e c k s
P a rt I ' V o lu m e 1 3 * © 2 0 1 7
 • h ypovolem ic
T h e s ta g e s o f s h o c k r e fle c t a p r o c e s s . T h e ty p e s o f s h o c k r e fe r to d iffe r e n t in itia l m e c h a n is m s o f
a c tio n th a t tr ip th o s e s ta g e s . T h e th r e e m a in c a te g o rie s a r e h y p o v o le m ic , c a r d io g e n ic , a n d d is trib u tiv e
s h o c k . D is trib u tiv e s h o c k c a n b e fu r th e r d e lin e a te d a s s e p tic , n e u r o g e n ic , a n d a n a p h y la c tic s h o c k .
• H ypo vo lem ic shock is th e m o s t c o m m o n ty p e o f s h o c k . It o c c u r s f r o m a la c k o f s u ffic ie n t flu id in
th e in tr a v a s c u la r s p a c e . T h e e tio lo g y o f th is is th a t th e h y p o v o le m ic s h o c k c a n o c c u r o n e o f tw o
w a y s . T h e firs t w ay is a n e x te rn a l lo s s o f b o d y flu id s u c h a s b lo o d o r p la s m a . A n a r te r ia l
la c e ra tio n th a t is n o t s to p p e d o r d o e s n o t s to p o n its o w n . A n o ther fo rm o f h y p o v o le m ic s h o c k is
w h e n flu id in th e b o d y is m o v e d to a n a r e a w h e r e it is n o t u s e d s u c h a s w h a t is c a lle d “ th ird "
s p a c in g . A n e x a m p le o f e x tr a c e llu la r flu id lo s s is s e v e re s o d iu m d e fic ie n c y . * ** T h e
p a th o p h y s io lo g y o f h y p o v o le m ic s h o c k is th a t w h e n flu id v o lu m e g o e s d o w n a d e c r e a s e in th e
c ir c u la tin g v o lu m e o f b lo o d is s e e n . W h e n th e c irc u la tin g v o lu m e o f b lo o d o c c u rs th e p r e lo a d to
th e h e a r t is d e c re a s e d . A d e c re a s e in p r e lo a d c a u s e s a d e c re a s e in s tr o k e v o lu m e w h ic h c a u s e s
a decrea se in the card iac output. W ith reduced ca rd iac o utp u t d e c r e a s e d c e llu la r o x y g e n
p e r fu s io n w ill o c c u r. W h e n c e lls d o n o t r e c e iv e e n o u g h o x y g e n th e y d ie .
• C ard iog en ic shock is w h e re th e h e a r t is u n a b le to p u m p fo r w a rd th e a m o u n t o f b lo o d in o n e
s tro k e to s u p p o r t life . T h is c a n o c c u r fo r s e v e r a l r e a s o n s . T h e e tio lo g y o f c a r d io g e n ic s h o c k is
s h o w n to b e o n e o f s e v e r a l p r o b le m s , th a t u ltim a te ly a ffe c t card iac o utput. T h e s e e x a m p le s
in c lu d e is c h e m ia o f th e le ft v e n tric le , s tru c tu r a l p r o b le m s , a n d d y s r h y th m ia s . A n y th in g th a t h in d e r s
th e flo w o f b lo o d o u t o f th e h e a r t c a n c a u s e c a r d io g e n ic s h o c k . W h e n b lo o d flo w o u t o f th e h e a r t
is d e c r e a s e d , th e re w ill b e a d e c r e a s e in o x y g e n a v a ila b ility to th e c e lls . T h is d e c r e a s e in o x y g e n
a v a ila b le to th e c e ll w ill c a u s e th e c e lls to s w itc h o v e r to a n a e ro b ic m e ta b o lis m , a n d th e w h o le
c y c le o f s h o c k is s ta r te d .
• D istrib u tive shock is a c o n d itio n w h e re th e flo w o f b lo o d is n o t e v e n ly d is trib u te d . It is a c tu a lly a n
u m b re lla fo r th r e e o th e r fo r m s o f s h o c k . T h e y a r e s e p tic , a n a p h y la c tic a n d n e u ro g e n ic s h o c k .
• A n ap h ylactic shock is w h e n th e b o d y 's a n tib o d y - a n tig e n r e s p o n s e is tr ig g e r e d b y s o m e th in g
th e p e r s o n is a lle r g ic to.
° N e urog en ic sh o ck is c a u s e d b y th e s u p p r e s s io n o r o u tr ig h t lo s s o f s y m p a th e tic to n e . It is
th e r a r e s t fo r m o f s h o c k . T h e e tio lo g y is a n y th in g w h ic h c a u s e s a n y d is ru p tio n o f th e
s y m p a th e tic n e r v o u s s y s te m . S o m e e x a m p le s o f th is a r e s p in a l in ju r y , s p in a l a n e s th e s ia ,
d ru g s a n d e m o tio n a l s tr e s s .
o S ep tic sh o c k ( S e p s is ) is th e in v a s io n o f th e b o d y b y b a c te r ia w h ic h c a u s e s a n im m u n e
r e s p o n s e . T h e r e s u ltin g fa llo u t is th a t tis s u e p e r fu s io n is im p a ire d a n d th e c y c le o f s h o c k is
b e g u n o n c e a g a in a t th e c e llu la r le v e l. T h e c la s s ic e x a m p le o f s e p tic s h o c k is T S S o r to x ic
s h o c k s y n d r o m e w h ic h is a n in v a s io n o f th e b o d y b y a to x in p r o d u c in g g r a m - p o s itiv e
b a c te r ia .
a n tib io tic s 262

W h ic h o f th e fo llo w in g a n tib io tic s is th e d ru g o f c h o ic e to b e u s e d as

a p r e m e d ic a tio n b e fo r e a n in v a s iv e d e n ta l p r o c e d u r e in a p a tie n t w ith
v a lv u la r d is e a s e to p r e v e n t th e ris k o f in fe c tiv e e n d o c a r d it is ?

• t e tr a c y c lin e
• a m o x ic illin

• s t r e p to m y c in
• e r y th r o m y c in

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • am oxicillin
In fe c tiv e e n d o c a r d itis is a n in fla m m a tio n o f th e e n d o th e lia l m e m b r a n e o f th e in n e r s u r fa c e o f th e h e a rt
a n d th e h e a r t v a lv e s c a u s e d b y th e m ic r o b ia l c o lo n iz a tio n . G r a m - p o s itiv e c o c c i o rig in a tin g fro m th e
o r o p h a r y n x , s k in , o r g a s tro in te s tin a l tra c t a re th e m a jo r c a u s a tiv e o r g a n is m s o f in fe c tiv e e n d o c a r d itis .
D e n ta l p ro c e d u r e s m a y c a u s e b a c te ria l e n try in to th e b lo o d s tre a m (b a c te r e m ia ) , w h ic h c a n c o lo n iz e
c a r d ia c v a lv e s . P r o p h y la c tic a n tib io tic m e d ic a tio n s h o u ld b e a d m in is te r e d b e fo re d e n ta l tre a tm e n ts in
p a tie n ts a t h ig h e s t r is k fo r a d v e r s e o u tc o m e s fr o m in fe c tiv e e n d o c a r d itis .
S in g le d o s e p r o p h y la c tic a n tib io tic re g im e n fo r in fe c tiv e e n d o c a r d itis , a d m in is te r e d 3 0 to 6 0 m in u te s
p r io r to d e n ta l p r o c e d u r e s is a s fo llo w s :
1. S tandard oral regim en:

A ntibiotic D o sage fo r adult D o sage fo r children

A m o x ic illin 2 .0 g P O 5 0 m g /k g PO
If unable to tak e oral m edication:

A ntibiotic D o sage fo r adult D osage fo r children

A m p ic illin o r 2 .0 g IM o r IV 5 0 m g /k g IM o r IV

C e ftria x o n e 1.0 g IM o r IV 5 0 m g /k g IM o r IV
3. If allergic to penicillin and able to take oral medication:

A ntibiotic D o sage fo r ad u lt D o sage fo r children

C lin d a m y c in o r 600 m g PO 15 m g /k g P O

A z ith ro m y c in o r 500 m g PO 15 m g /k g PO

C la r ith r o m y c in o r 5 0 0 m g PO 15 m g /k g PO

C e p h a le x in 2 g PO 5 0 m g /k g PO

4. If allergic to penicillin and unable to take oral medication:

Antibiotic D o sage fo r adult D o sage fo r children

C e fa z o lin o r C e ftria x o n e 1 .0 g IM o r IV 50 m g /k g IM o r IV

C lin d a m y c in 6 0 0 m g IM o r IV 20 m g /k g IM o r IV
a n tib io tic s 263

N y s ta tin a n d C lin d a m y c in a r e th e tw o a n tifu n g a ls u s e d a s “ s w is h a n d

s w a llo w ” t r e a tm e n ts fo r o ra l c a n d id ia s is .
N y s ta tin is ta k e n a s a tr o c h e (lo z e n g e ) th a t is s lo w ly d is s o lv e d in th e
m o u th a n d s w a llo w e d .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e

• th e f ir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • b o th s ta te m e n ts a re fa ls e
C a n d id ia s is is a n in fe c t io n , u s u a lly o f th e o r a l c a v it y o r v a g in a , w it h a C a n d id a
s p e c ie s , u s u a lly C. albicans , w h ic h c a u s e s a n in f la m m a t o r y , p r u r it ic in fe c tio n
c h a r a c t e r iz e d b y a th ic k , w h it e d is c h a r g e . It is c o m m o n , e s p e c ia lly in p a tie n ts
w h o h a v e a d e f ic ie n c y in T - ly m p h o c y t e s , o r w h o a r e r e c e iv in g c h e m o th e r a p y ,
a n d in im m u n o s u p p r e s s e d in d iv id u a ls ( A ID S p a tie n ts ) . T h is y e a s t - lik e f u n g i is
a n o rm a l in h a b ita n t o f th e o r a l c a v ity a n d v a g in a l tr a c t, h o w e v e r it is n o r m a lly
h e ld in c h e c k b y th e in d ig e n o u s b a c t e r ia o f t h e s e a r e a s . N o te: A n g u la r
c h e ilitis ( b ila te r a l u lc e r s a t th e c o r n e r o f t h e m o u th ) h a s b e e n lin k e d t o C.
albicans.
C o r tic o s te ro id u s a g e c a n a ls o le a d t o c a n d id ia s is in p e o p le w h o t a k e th o s e
t y p e s o f m e d ic a t io n s f o r a s th m a , o r p r im a r y a d r e n a l in s u ff ic ie n c y .
R e m e m b e r: N y s ta tin a n d c lo t r im a z o le a r e th e tw o a n t if u n g a ls t h a t a r e u s e d
as “ s w is h an d s w a llo w ” t o t r e a t o r a l C a n d id a in fe c tio n s . N y s ta tin
( M y c o s ta tin ) is ta k e n a s a n o r a l s u s p e n s io n to b e s w is h e d a r o u n d th e m o u th
a n d s w a llo w e d . C lo tr im a z o le ( M y c e le x ) is ta k e n a s a tr o c h e ( lo z e n g e ) w h ic h is
s lo w ly d is s o lv e d in t h e m o u th a n d s w a llo w e d . T h e y w o r k b y b in d in g t o s te r o ls
in th e fu n g a l c e ll m e m b r a n e , in c r e a s in g p e r m e a b ilit y a n d p e r m it t in g th e
le a k a g e o f in t r a c e llu la r c o m p o n e n ts . T h is le a d s t o th e d e a th o f th e a ff e c te d
f u n g a l c e ll.
„ 1. A v a g in a l c a n d id ia s is in fe c tio n c a n p r o d u c e a th ic k , w h it e
d is c h a r g e .
2 . A n g u la r c h e ilit is ( b ila te r a l u lc e r s a t th e c o r n e r o f th e m o u th ) h a s
b e e n lin k e d t o C. albicans.
a n tib io tic s 264

W h ic h a n tib io tic is u sed c a u tio u sly d u e to its s id e effec ts

(p s e u d o m e m b ra n o u s co litis , s ev e re Gl u p s et)?

• a z it h r o m y c in ( z ith r o m a x ; Z - P a k )
• c lin d a m y c in

• p e n ic illin V K
• c e p h a le x in ( k e fle x )

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 c lin d a m y c in
S u m m a r y o f I m p o r ta n t A n tib io tic s

D ru g A n ti b a c te ri a l A c tio n A n t i b a c te ri a l M e c h a n is m Im p o r t a n t A d v e rs e E ffe c ts

P e n ic illin s : In h ib its c e ll w a ll s y n th e s is B a c te ric id a l H y p e rs e n s itiv ity

P e n ic illin V K
A m o x ic illin
A m o x ic illin /C la v u lu n a te
( A u g m e n t in )
A m p ic illin

C e p h a lo s p o r in s : In h ib its c e ll w a ll s y n th e s is B a c te ric id a l H y p e rs e n s itiv ity

C e p h a le x in ( K c llc x )
C e f a c lo r (C e c lo r)
O th e r:
C lin d a m y c in In h ib its 5 0 S rib o s o m e s B a c te rio s ta tic P s e u d o m e m b ra n o u s c o litis

M a r rn l id e s : In h ib its SO S rib o s o m e s B a c te rio s ta tic

A z ith r o m y c in (7 ,-P a k ) N o n e s ig n ific a n t

C la rith ro m y c in ( B ia x in ) G I h y p e ra c tiv ity

E r y th ro m y c in G 1 h y p e ra c tiv ity

T e tr a c y c lin e s : In h ib its 3 0 S rib o s o m e s B a c te rio s ta tic

T e tra c y c lin e S u p e rin fe c tio n s

D o x y c y c lin e (V ib rn m y c in ) N o n e S ig n ific a n t

M in o c y c lin e (M in o c in ) N o n e S ig n ific a n t

A m in o g ly c o s id e s : I n h ib its 3 0 S rib o s o m e s B a c te ric id a l O to to x ic ity , N e p h ro to x ic ity

S tre p to m y c in
(ie n ln m y c in

M is c e lla n e o u s :
C ip ro flo x a c in (C ip ro ) In h ib its D N A B a c te ric id a l N au sea, headache

B a c itra c in In h ib its c e ll w a ll s y n th e s is B a c te ric id a l N e p h r o to x ic ity

C h lo ra m p h e n ic o l In h ib its 5 0 S rib o s o m e s B a c te rio s ta tic B l o o d d is o r d e rs

N o te: T h e m o s t c o m m o n c lin ic a l c a u s e o f b a c te ria l re s is ta n c e is t h e u s e o f

a n t ib io t ic s w h e n t h e y a re n o t in d ic a te d .
a n tib io tic s 265

A p a tie n t a lle rg ic to p en icillin is m o s t likely to h ave a c ro s s a lle rg y

w ith a:

• c a rb a p e n e m
• m a c r o lid e
• q u in o lo n e
• c e p h a lo s p o r in
• g ly c o p e p tid e

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 13 • © 2 0 1 7
 • cephalosporin
The c e p h a lo s p o r in s a re p e n ic illin - lik e in a c tio n a g a in s t b a c te r ia . T hey a re
bactericidal a n tib io tic s th a t a c t lik e th e p e n ic illin s a n d in te r fe r e w ith cell wall
synthesis th r o u g h in h ib itio n o f th e s y n th e s is o f th e p e p tid o g ly c a n in th e c e ll w a ll. T h e
a n tib io tic b in d s to th e e n z y m e s (i.e ., tr a n s p e p tid a s e ) th a t b u ild /m a in ta in th e c e ll w a ll.
T h is m a k e s th e c e ll w a ll o s m o tic a lly u n s ta b le . B a c te r ia e v e n tu a lly ly s e , r e s u ltin g in
d e a th o f th e c e ll.
C u r re n tly , th e r e a re four generations o f c e p h a lo s p o r in s . E a c h n e w e r g e n e r a tio n h a s
s ig n ific a n tly g r e a te r gram -negative antim icrobial properties th a n th e p r e c e d in g
o n e , a n d a d e c r e a s e d m a x im u m a c tiv ity a g a in s t g ra m -p o s itiv e o r g a n is m s .
Im p o r ta n t cephalosporins w ith in e a c h g e n e r a tio n :
• F irs t: c e p h a le x in ( K e fle x ) , c e p h r a d in e ( V e lo s e f) , c e fa d r o x il ( D u r ic e f) , c e fa z o lin
(A n c e f). M o s t a c tiv e a g a in s t S. aureus, G r o u p A B e ta - h e m o ly tic s tr e p to c o c c i, a n d
P neum ococcus.
• Second: c e fa c lo r ( C e c lo r ), c e fu r o x im e (C e ftin ), c e fo x itin ( M e fo x in ) , c e fp r o z il
( C e fz il), c e fp o d o x im e (V a n tin ). S till h a v e e ffic a c y a g a in s t g ra m -p o s itiv e
o r g a n is m s b u t a ls o p o s s e s s g o o d a c tiv ity a g a in s t E. coli a n d H. influenzae.
• Third: c e fix im e ( S u p r a x ) , c e fo p e r a z o n e ( C e fo b id ) , c e ftr ia x o n e (R o c e p h in ) . H a v e
th e b r o a d e s t s p e c tr u m o f a c tiv ity o f a ll c e p h a lo s p o r in s a n d a re e x tr e m e ly e ffe c tiv e
a g a in s t g ra m -n e g a tiv e o r g a n is m s . T h e y a re m o re a c tiv e a g a in s t E. coli, Klebsiella
pneumoniae, E n te r o b a c te r , S a lm o n e lla , a n d S h ig e lla .
• Fourth: c e fe p im e ( M a x ip im e ) . E ffe c tiv e a g a in s t Pseudomonas aeruginosa.
Note: A p p r o x im a te ly 10% o f in d iv id u a ls e x p r e s s in g a lle r g y to th e p e n ic illin fa m ily of
a n tib io tic s w ill h a v e cross allergenicity to th e c e p h a lo s p o r in s .
Rem em ber: A n tib io tic s c o n ta in in g th is b e ta - la c ta m rin g a re r e fe r re d to c o lle c tiv e ly a s
beta-lactam antibiotics a n d in c lu d e th e p e n ic illin s , c e p h a lo s p o rin s , a n d th e tw o
n e w e r g r o u p s o f a g e n ts , th e c a r b a p e n e m s a n d th e m o n o b a c ta m s .
a n tib io tic s 266

E ach o f th e fo llo w in g a n tib io tic s a c t by a ffe c tin g th e b a cte ria l cell

w all E X C E P T o n e. W h ic h o n e is th e E X C E P T IO N ?

• b a c itr a c in
• a z it h r o m y c in

• p e n ic illin
• v a n c o m y c in

• a z tr e o n a m

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 a z ith r o m y c in
M e c h a n is m o f a c tio n o f a n t ib io t ic s o n th e b a c te r ia l c e ll:
• A g e n t s a ff e c tin g b a c te r ia l c e ll w a ll:
- P e n ic illin s - V a n c o m y c in - Im ip e n e m
- C e p h a lo s p o r in s - C y c lo s e r in e
- B a c itr a c in - A z tre o n a m
• A g e n t s in t e r f e r in g w it h p r o te in s y n th e s is :
- T e tr a c y c lin e - E r y th r o m y c in - A z it h r o m y c in
- A m in o g ly c o s id e s - L in c o m y c in - C la r ith r o m y c in
- C h lo r a m p h e n ic o l - C lin d a m y c in
• A g e n t s in te r fe r in g w ith n o r m a l b io s y n t h e t ic p a th w a y s :

- S u lf o n a m id e s
- T r im e t h o p r im
- F lu o r o q u in o lo n e s (i.e ., c ip r o flo x a c in , n o r flo x a c in , le v o flo x a c in , m o x if lo x a c in ,
a n d g e m iflo x a c in )
a n tib io tic s 267

T e tra c y c lin e s a re th e d rug s o f firs t c h o ice in th e tre a tm e n t o f all of the

fo llo w in g E X C E P T o n e. W h ic h o n e is th e E X C E P T IO N ?

• m y c o p la s m a p n e u m o n ia
• c h la m y d ia in f e c tio n s
• r ic k e tts ia l in f e c tio n s
• s t a p h y lo c o c c a l in f e c tio n s

M IC R O B IO L O G Y /P A T H O L O G Y l* d e n t a ld e c l< S
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 staphylococcal infections
P o p u la r Tetracyclin es in c lu d e :
• Tetracycline: u s e d to tre a t a c n e , g o n o rrh e a , a n d s y p h ilis in p a tie n ts a lle r g ic to
p e n ic illin . A ls o u s e d to tr e a t e x a c e r b a tio n s o f c h r o n ic b r o n c h itis , a s w e ll as
M y c o p la s m a , C h la m y d ia , a n d R ic k e tts ia in fe c tio n s . Remember: T e tr a c y c lin e can
c a u s e s ta in in g a n d d is c o lo r a tio n o f fo r m in g te e th a n d a ls o a ffe c t b o n e g ro w th in
fe ta l d e v e lo p m e n t.
• M inocycline ( M in o c in ): u s e d to tr e a t a c n e , a n th r a x a n d m e n in g o c o c c a l p r o p h y la x is
• Doxycycline ( V ib r a m y c in ) : u s e d to tre a t in fe c tio n s c a u s e d b y R ic k e tts ia ,
C h la m y d ia , a n d M y c o p la s m a ; a lte r n a tiv e to m e flo q u in e fo r m a la r ia p ro p h y la x is a n d
tr e a tm e n t o f s y p h ilis
Remember: T h e ric k e tts ia a re sm all, gram -negative, aerobic, coccobacillary
b a c te ria th a t a re o b lig a te in tra c e llu la r p a ra s ite s . T h e y c o n ta in both R N A a n d D N A ,
w h ile v ir u s e s c o n ta in either R N A o r D N A . H u m a n r ic k e tts ia l in fe c tio n r e s u lts fro m
in s e c t b ite s . T h e h u m a n ta r g e t c e ll fo r all ric k e tts ia e is th e endothelial cell of
c a p illa r ie s a n d o th e r s m a ll b lo o d v e s s e ls . H u m a n r ic k e tts ia l in fe c tio n s p r e s e n t as
s y s te m ic s y m p to m s o f h e a d a c h e , m y a lg ia s , a n d fe v e r , follow ed by a rash. T h e y are
tr a d itio n a lly d iv id e d in to tw o g r o u p s a s s e e n b e lo w .
D is e a s e s T ra n s m is s io n

S p o tte d -F e v e r G r o u p :
R o c k y M o u n ta in s p o tte d fe v e r 1i c k s
Q u e e n s la n d tic k fe v e r T ic k s

B o u to n n e u s e fe v e r, K e n y a tic k fe v e r T ic k s

S ib e r iu n tic k f e v e r T ic k s
R ic k e tts ia lp o x M ite s

T y p h u s G ro u p :
L o u s e -b o r n e ty p h u s ( e p id e m ic ty p h u s ) I .ic e
M u r in e ty p h u s ( e n d e m ic ty p h u s ) F le a s

S c r u b ty p h u s M ite s

Q fe v e r I n h a la tio n
a n tib io tic s 268

W h ic h p e n icillin is p re s c rib e d p rim a rily in th e tre a tm e n t o f s ev e re

p e n ic illin a s e -p ro d u c in g s ta p h y lo c o c c a l in fe c tio n s ?

• m e th ic illin
• a m p ic illin

• p e n ic illin V K
• c a r b e n ic illin

M IC R O B IO L O G Y /P A T H O L O G Y H M e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • m e th ic illin
M e t h ic illin is n o t fre q u e n tly u s e d b e c a u s e o f t h e in c id e n c e o f in te r s titia l
n e p h r itis a n d t h e a v a ila b ility o f e q u a lly e ff ic a c io u s a lt e r n a t iv e s ( n a f c illin a n d
o x a c illin ) . It is g iv e n th r o u g h IV in s e v e re p e n ic illin a s e - p r o d u c in g
s t a p h y lo c o c c a l in fe c t io n s .
R e m e m b e r: P e n ic illin a s e is p r o d u c e d b y c e r ta in b a c te r ia ( e . g ., s o m e s tr a in s
o f s t a p h y lo c o c c i) t h a t r e n d e r p e n ic illin in a c t iv e . It d e g r a d e s th e b e ta -la c ta m
rin g s tru c tu re o f p e n ic illin . S t r u c t u r a l m o d if ic a t io n o f p e n ic illin G ( e .g .,
m e th ic illin ) , c a n r e n d e r t h e m o le c u le r e s is t a n t t o p e n ic illin a s e s , b u t m a y a ls o
n a r r o w t h e s p e c t r u m o f a c tio n , lim it in g th e p r im a iV u s e o f s u c h a n ti b io t ic s to
t h e t r e a t m e n t o f in fe c tio n s c a u s e d b y S t a p h y lo c o c c u s s p e c ie s .
O t h e r p e n ic illin a s e - r e s is t a n t p e n ic illin s in c lu d e c lo x a c illin , d ic lo x a c illin , n a f c illin ,
o x a c illin , a m o x ic illin / c la v u la n a t e p o t a s s iu m ( A u g m e n t in ) , a m p ic illin / s u lb a c t in
(U n a s y n ), p ip e r a c illin / t a z o b a c t a m (Z o s y n ), and t ic a r c illin / c la v u la n a t e
p o t a s s iu m ( T im e n tin ) .
1. M e t h ic illin - r e s is t a n t Staphylococcus aureus ( M R S A ) is a g r o u p o f
r e s is ta n t Staphylococcus, b a c te r ia t h a t c a n b e lif e - th r e a te n in g .
T h e s e b a c te r ia a r e r e s is ta n t t o a ll t h e p e n ic illin a s e - r e s is t a n t
p e n ic illin s a n d c e p h a lo s p o r in s . S u c h s t r a in s a r e u s u a lly r e s is t a n t a s
w e ll t o a m in o g ly c o s id e s , t e tr a c y c lin e s , e r y t h r o m y c in s , a n d
c lin d a m y c in . In t h e p a s t, v a n c o m y c in h a s b e e n u s e d a g a in s t
M R S A . H o w e v e r , m ic r o o r g a n is m s r e s is ta n t to v a n c o m y c in h a v e
b e e n r e p o r te d a n d its u s e h a s b e e n c u r ta ile d .
2 . P e n ic illin w ill w o r k o n ly o n g r o w in g c e lls t h a t c o n ta in p e p tid o g ly c a n
in t h e ir c e ll w a ll. T h is is w h y p e n ic illin s h o w s its g r e a t e s t b a c te r ic id a l
a c tiv ity a g a in s t g r o w in g g r a m - p o s it iv e b a c te r ia ( th e y h a v e a t h ic k
p e p tid o g ly c a n o r m u r e in la y e r in t h e ir c e ll w a ll) . R e m e m b e r:
P e n ic illin in h ib it s t h e t e r m in a l s te p in p e p t id o g ly c a n s y n th e s is .
a n tib io tic s 269

W h ic h o f th e fo llo w in g is c la s s if ie d a s a n a n tifu n g a l a g e n t?

• b a c itr a c in
• a m p h o te r ic in - B
• p o ly m y x in - B
• n e o m y c in

M IC R O B IO L O G Y /P A T H O L O G Y (g fr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • a m p h o te r ic in -B
T h is is a n a n tifu n g a l a g e n t g iv e n in tr a v e n o u s ly o r o r a lly f o r th e t r e a t m e n t o f
s e v e r e s y s t e m ic fu n g a l in f e c t io n s c a u s e d b y f u n g i s u c h a s Candida s p e c ie s .
B a c itr a c in , p o ly m y x in B , a n d n e o m y c in a r e a n tib io tic s . A n t ib io t ic s in g e n e r a l
d o n o t h a v e a n t if u n g a l p r o p e r tie s . A m p h o t e r ic in B a n d N y s ta tin a r e p o ly e n e
a n tifu n g a l a n tib io tic s w h ic h b in d t o s te r o ls , p r e f e r e n t ia lly t o th e p r im a r y
fu n g a l c e ll m e m b r a n e s te r o l, e r g o s te r o l. T h is b in d in g d is r u p t s o s m o t ic
in te g r ity o f th e fu n g a l c e ll m e m b r a n e , r e s u ltin g in le a k a g e o f in t r a c e llu la r
c o m p o n e n t s a n d th e n c e llu la r d e a th .

S u m m a ry o f S o m e A n tifu n g a l A g e n ts

U se I M e c h a n i s m o n fu n g a l c e ll | F o rm

T o p ic a l A g e n ts ( d is s o lv e a n d sw a llo w )

C lo trim a z o le ( M v c e le x T ro c h e ) O ro p h a ry n g e a l c a n d id ia s is A lte rs c e ll m e m b r a n e T ro ch e

N y s ta tin (M y c o s ta tin ) O ra l c a v ity c a n d id ia s is A lte rs c e ll m e m b ra n e O ra l S u s p e n s io n

T o p ic a l A g e n ts (c r e a n V o in tin e n t)

A n ip h o tc ric in -B (F u n g iz o n e ) A lte rs c e ll m e m b ra n e C ream

K e to c o n a /o le (N iz o ra l) \ C u ta n e o u s a n d m u c o c u - A lte rs c e ll m e m b ra n e C ream

N y s ta tin (M y c o s ta tin ) j ta n e o u s c a n d id ia s is A lte rs c e ll m e m b ra n e O in tm e n t

S y s te m ic A g e n t s

A m p h o tc ric in -B (F u n g iz o n e ) S y s te m ic C a n d id a A lte rs c e ll m e m b ra n e I V in je c tio n

K c to c o n a z o le (N iz o ra l) O ra l e s o p h a g e a l c a n d id ia s is A lte rs c e ll m e m b ra n e T a b le ts

F lu c o n a z o le (D iflu c a n ) O ra lp h a ry n g e a l c a n d id ia s is A lte rs c e ll m e m b ra n e T a b le ts

N o te : S y s t e m ic a m p h o t e r ic in B is a s s o c ia t e d w it h a h ig h in c id e n c e o f k id n e y
to x ic ity .
Im p o r ta n t: A n t if u n g a l d ru g s a ffe c t c e ll m e m b ra n e p e r m e a b ilit y , c a u s in g
le a k a g e o f c e llu la r c o n s titu e n ts , w h ic h le a d s t o th e d e a th o f th e a ff e c t e d c e lls .
o ra l c a v ity 270

T h e m a jo r c a r io g e n ic p r o p e r ty o f S tre p to c o c c u s m u ta n s a p p e a r s to
b e its a b ility to p r o d u c e w h ic h o f t h e fo llo w in g e n z y m e s ?

• la c ta s e
• b e t a - g lu c o s id a s e
• c e llu la s e
• g lu c o s y lt r a n s fe r a s e

M IC R O B IO L O G Y /P A T H O L O G Y ® * d e n ta ld e c k s
P a r i I • V o lu m e 1 3 • © 2 0 1 7
 • g lu c o s y ltra n s fe ra s e
D e n ta l c a rie s h a s b e e n a n in tra c ta b le d is e a s e in s p ite o f in te n s e d e n ta l r e s e a rc h . T h e
m e ta b o lic a c id s p ro d u c e d b y m u tan s s tre p to c o cc i d e m in e r a liz e th e to o th s u rfa c e a nd
lea d to d e n ta l c a rie s . T h e e n z y m e g lu c o s y ltra n s fe ra s e (a k a , d e x tra n s u c ra s e )
p ro d u c e d b y m u ta n s s tr e p to c o c c i is th e k e y fa c to r in th is p ro c e s s . O ra l b a c te ria l
g lu c o s y l tr a n s fe r a s e s (G T F s ) u s e s u c ro s e a s a s u b s tr a te in s y n th e s is o f e ith e r w a te r-
s o lu b le o r in s o lu b le g lu c a n s (e .g ., d e x tra n s , m u ta n s , a n d le v a n s ).

Im p o rtan t p oint: T h e m a jo r c a rio g e n ic p ro p e rty o f S. mutans a p p e a rs to b e its a b ility

to p ro d u c e th e e n z y m e g lu c o s y ltra n s fe ra s e . * * * Streptococcus mutans is th e p rim a ry
e tio lo g ic a g e n t in itia tin g d e n ta l c a rie s .
S. sanguis (w h ic h is th e m o s t fr e q u e n tly is o la te d Streptococcus in th e o ra l c a v ity ), S.
salivarius, a n d Lactobacillus s p e c ie s a ls o p ro d u c e g lu c o s y l tr a n s fe r a s e . T h is e n z y m e
c a ta ly z e s th e fo rm a tio n o f e x tr a c e llu la r g lu c a n s fro m d ie ta r y s u c ro s e . G lu c a n
p ro d u c tio n c o n tr ib u te s to th e fo rm a tio n of d en tal p laq u e. T h is d e n ta l p la q u e h o ld s th e
la ctic a c id w h ic h is p ro d u c e d b y th e s e S tre p to c o c c i a g a in s t th e to o th . T h is a c id
d is s o lv e s th e h y d r o x y a p a tite c ry s ta ls w h ic h fo rm th e e n a m e l o f th e to o th , c re a tin g
c a rie s .
S tre p to c o c c i h a v e th e s e e s s e n tia l p ro p e rtie s n e c e s s a r y fo r c a r ie s fo rm a tio n :
• T h e y a d h e re to to o th s u rfa c e (c o lo n iz e o n to o th s u rfa c e )
• T h e y p ro d u c e la ctic a c id , w h ic h w ill d is s o lv e th e e n a m e l o f th e to o th
• T h e y p ro d u c e a p o ly m e r ic s u b s ta n c e (fro m th e m e ta b o lis m o f c a rb o h y d ra te s ),
w h ic h c a u s e s th e a c id to re m a in in c o n ta c t w ith th e to o th
R em em b er: P re re q u is ite s fo r th e d e v e lo p m e n t o f c a rie s :
1. C a r io g e n ic b a c te ria
2. S u s c e p tib le h o s t
3. S u p p ly o f s u b s tr a te fo r la c tic a c id p ro d u c tio n
m 1. A c tin o m y c e s v is c o s u s a n d n a e s lu n d ii c a u s e ro o t-s u rfa c e c a rie s .
2. A ctin o b a c illu s s p e c ie s a re g ra m - n e g a tiv e c o c c o b a c illa ry ro d s . Im p o rtan t:
A A is m o s t c o m m o n ly im p lic a te d w ith th e e tio lo g y o f th e lo c a liz e d
a g g re s s iv e (ju v e n ile ) p e rio d o n titis a n d p e r io d o n titis in ju v e n ile d ia b e te s .
o ra l c a v ity 271

W h ic h o f th e fo llo w in g d o e s n o t a p p ly to c h lo r h e x id in e g lu c o n a te ?

• p la q u e c o n tr o l a c tiv it y
• b r o a d a n tim ic r o b ia l a c t iv ity
• s u b s ta n tiv ity
• a n ti- s e n s itiv ity a c tiv ity

M IC R O B IO L O G Y /P A T H O L O G Y H ^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a n ti-s e n s itiv ity a c tiv ity
C h lo r h e x id in e is a b r o a d s p e c tr u m a n t im ic r o b ia l a g e n t u s e d a g a in s t g r a m ­
p o s itiv e b a c te r ia , g r a m - n e g a t iv e b a c te r ia , a n d f u n g i. It is a c a tio n ic
b is b ig u a n id e t h a t w o r k s b y r u p tu r in g m ic r o b ia l c e ll m e m b r a n e s .
C h lo r h e x id in e is fo r m u la t e d as to p ic a l a n t im ic r o b ia l m o u th r in s e s in
c o n c e n tr a tio n o f 0 .1 2 % in th e U n ite d S ta te s a n d 0 .2 % o u ts id e th e U n ite d
S ta te s . It is a ls o a v a ila b le a s a s u s ta in e d r e le a s e s y s te m in fo r m o f a 2 .5
m g c h lo r h e x id in e c h ip in a h y d r o ly z e d g e la tin b io d e g r a d a b le film .
C h lo r h e x id in e e x h ib it s th ep r o p e r t y o f h ig h s u b s ta n tiv ity b y b in d in g to
p r o te in s in hum an tis s u e t h a t a llo w s th e p r o lo n g e d a d h e re n c e of
c h lo r h e x id in e to t h e o r a l s u r f a c e s ( b o th s o f t a n d h a r d tis s u e s ) f o r a lo n g p e r io d
a n d s lo w a c tiv e r e le a s e o f th e in g r e d ie n t a llo w s f o r p e r s is te n c e o f its m ic r o b ia l
a c tiv ity .
U s e s o f c h lo r h e x id in e in d e n tis tr y :
1. P la q u e c o n t r o l a g e n t
2. A n ti - g in g iv it is a g e n t f o r lo n g - te r m u s e
3. D e n tu r e d is in f e c t a n t
4. P r e - r in s e d u r in g p e r io d o n t a l t h e r a p y a n d in s t r u m e n t a t io n
5. W o u n d h e a lin g a f t e r s u r g e r y
O th e r u s e s o f c h lo r h e x id in e in c lu d e :
1. S k in a n t is e p t ic a n d w o u n d c le a n s e r f o r p r e - s u r g ic a l p r e p a r a tio n
2. H a n d w a s h a n d s u r g ic a l s c r u b f o r h e a lth c a r e p e r s o n n e l
3. P r e s e r v a t iv e in o p h t h a lm ic p r o d u c t s
4. A n t im ic r o b ia l f o r t h e p e r ito n e a l c a v ity a n d u r in a r y b la d d e r ( v e r y d ilu t e
c o n c e n t r a t io n )
A d v e rs e e ffe c ts o f c h lo r h e x id in e a r e s t a in in g o f t e e th , a lte r e d ta s te
s e n s a tio n , r e v e r s ib le d e s q u a m a t io n , a n d s u p r a g in g iv a l c a lc u lu s d e p o s it s o v e r
tim e .
o ra l c a v ity 272

W h ic h o f th e fo llo w in g b a c te r ia a re fir s t to c o lo n iz e th e o ra l c a v ity o f

n e w b o rn in fa n ts ?

• Fusobacterium s p e c ie s
• Streptococcus salivarius
• Lactobacillus s p e c ie s
• Streptococcus mutans

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • Streptococcus salivarius
Streptococcus salivarius and Streptococcus mitis a re th e firs t an d m ost
d o m in a n t m ic r o o r g a n is m s to ta k e o v e r th e o ra l c a v ity o f a n e w b o r n . T h o u g h n o t
d o m in a n t, Veillonella, Neisseria, Staphylococcus, an d Actinomyces sp ec ies also
fo rm e a rly c o lo n ie s in th e o ral c av ity. S o o n a fte r b irth , th e s te r ile o ra l m ic r o flo r a of
n e w b o r n is r e p la c e d b y lo w n u m b e r s o f fa c u lta tiv e a n d a e r o b ic b a c te r ia . T h e s e
c o lo n ie s o f b a c te r ia r e s e m b le e ith e r th e v a g in a l m ic ro b io ta o f th e m o th e r o r, in
n e w b o r n s d e liv e r e d b y c e s a r e a n b irth , th e m o th e r ’s s k in m ic r o b io ta . A n a e r o b ic
b a c te r ia c a n b e fo u n d in th e e d e n tu lo u s m o u th o f th e in fa n t fr o m th e s e c o n d d a y a fte r
b irth . O v e r tim e , e x p o s u r e to e x te r n a l e n v ir o n m e n ta l fa c to r s le a d s to a n in c re a s e in
th e n u m b e r o f o ra l b a c te ria .
O n c e te e th e ru p t, a m o r e c o m p le x m ic r o b io ta in h a b its th e o ra l c a v ity , in c lu d in g
Streptococcus sanguinis, Lactobacillus s p e c ie s , a n d Streptococcus oralis. A fte r o n e
y e a r, th e o ra l c a v ity is c o lo n iz e d b y s tr e p to c o c c i s p e c ie s s u c h a s Streptococcus
oralis, Streptococcus anginosus, Streptococcus mutans, a n d Streptococcus gordonii.
Y o u n g c h ild r e n c a n a ls o h a r b o r a n a e r o b e s s u c h a s Fusobacterium a n d Prevotella
s p e c ie s . A s m o r e te e th e r u p t in th e o ra l c a v ity , th e c o m p le x ity , d iv e r s ity , a n d n u m b e r s
o f b a c te r ia c o lo n iz in g th e o ra l c a v ity in c re a s e s .
M ic ro b ia l s h ifts fro m th e h ea lth y to d is e a s e d p e r io d o n tiu m in th e o ral c a vity
in c lu d e:
• G r a m -p o s itiv e b a c te r ia —> g ra m - n e g a tiv e b a c te r ia
• C o c c i —> ro d s
• N o n m o tile o r g a n is m s —> m o tile o r g a n is m s
• F a c u lta tiv e a n a e r o b e s —> o b lig a te a n a e r o b e s
• F e r m e n tin g s p e c ie s —►p r o te o ly tic s p e c ie s
In th e o ra l c a v ity , a u n iq u e e c o lo g ic a l n ic h e o f th e o ra l flo r a e x is ts . B a c te r ia th a t
p re fe re n tia lly c o lo n iz e th e to o th s u rfa c e a re Streptococcus sanguis,
Streptococcus mutans, Streptococcus mitis, a n d Actinomyces viscosus. B a c te r ia th a t
u s u a lly c o lo n iz e th e to n g u e an d b uccal m u co sa a re Streptococcus salivarius a n d
Veillonella s p e c ie s w h ile Fusobacterium, Porphyromonas, Prevotella, a n d a n a e r o b ic
s p iro c h e te s a re c o n c e n tr a te d in th e g in g iv a l cre v ice .
o ra l c a v it y 273

O r d e r th e s ta g e s in p la q u e fo r m a tio n . M a tc h e a c h le tte r w ith its

p ro p e r s e q u e n c e n u m b e r.

A . S tr e p to c o c c i c o lo n iz e th e a c q u ir e d
p e llic le
2. _
B . F ila m e n to u s b a c te r ia c o lo n iz e th e
3 . _______
a c q u ir e d p e llic le
4 . _______
C . F o r m a t io n o f th e p e llic le
5 . _______
D . R o d - s h a p e d m ic r o o r g a n is m s
c o lo n iz e th e a c q u ir e d p e llic le
E . C a lc ific a tio n o f th e c r y s ta llin e
s tr u c tu r e

M IC R O B IO L O G Y /P A T H O L O G Y !► d e n ta ld ec ks
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 1. C , 2 . A , 3 . D, 4 . B, 5. E

S ta g e s in p la q u e fo r m a tio n :
1. F o r m a tio n o f th e p e llic le ( a c q u ir e d p e llic le ) : T h e p e llic le is a s u r fa c e
c o a tin g o f s a liv a r y o r ig in , w h ic h is p r im a r ily p r o te in in n a tu r e , w ith s o m e
c a r b o h y d r a t e c o m p le x e s . It is e s s e n t ia lly s t r u c t u r e le s s a n d b a c t e r ia - f r e e . It
w ill fo r m o n a c le a n to o t h s u r fa c e w it h in a m a t t e r o f m in u t e s b e c a u s e o f its
s a liv a r y o r ig in . It a ls o w ill fo r m o n c r o w n s , d e n tu r e s , p o r c e la in te e t h , e tc .
2 . B a c te r ia l c o lo n iz a t io n : T h e b a c t e r ia a r e d e p o s it e d u p o n th e p e llic le in a
s o m e w h a t o r d e r ly f a s h io n . T h e f ir s t g r o u p to a p p e a r o n th e s u r fa c e o f th e
a c q u ir e d p e llic le is s t r e p t o c o c c i ( g r a m - p o s it iv e c o c c i) . T h e y c o lo n iz e in
t r e m e n d o u s ly la r g e n u m b e r s . F o llo w in g e s t a b lis h m e n t o f th e c o c c a l fo r m s
o f b a c te r ia , r o d - s h a p e d m ic r o o r g a n is m s ( B a c t e r o id e s a n d F u s o b a c te r iu m )
a tt a c h to a n d c o lo n iz e th e to o t h s u r f a c e s . A s th e p la q u e m a tu r e s , th e
b a c te r ia l m o r p h o lo g y s h if t s to in c lu d e f ila m e n t o u s t y p e s ( A c tin o m y c e s ) .
N o te : B a c te r ia l p la q u e is m o s t ly c o m p o s e d o f w a t e r ( 8 0 % ) . T h e r e m a in in g
s o lid c o m p o n e n t ( 2 0 % ) is c o m p r is e d m o s t ly o f b a c t e r ia ( 9 5 % ) . T h e d if f e r e n t
t y p e s o f b a c t e r ia fo u n d in p la q u e a n d t h e ir p r o p o r t io n s c h a n g e w it h tim e ,
d ie t, a n d lo c a tio n .
3 . M a tu r a tio n s ta g e : S a liv a c o n t in u e s to p r o v id e a g g lu t in a t in g s u b s t a n c e s
a n d o t h e r p r o t e in s to th e in t e r c e llu la r m a tr ix , a n d b a c te r ia l in t e r c e llu la r
a d h e s io n r e s u lts . T h e c r y s t a llin e s tr u c t u r e w ill in c r e a s e a n d e v e n tu a lly
c a lc ify ( c a lc u lu s ) .
o ra l c a v ity 274

W h ic h o f th e fo llo w in g c o n s titu e n ts fo r m th e s tr u c tu r e o f m a te ria

a lb a ?

• b a c te r ia , s a liv a r y p r o te in s , d e s q u a m a te d e p it h e lia l c e lls , a n d le u k o c y te s

• b a c te r ia , g ly c o p r o t e in , s a liv a r y lip id s , a n d h y d r o x y a p a tit e
• b a c t e r ia , le u k o c y te s , p o ly s a c c h a r id e c o m p le x , a n d m u c in
• b a c te r ia , c a lc iu m c a r b o n a te , m a g n e s iu m p h o s p h a te , a n d b lo o d c e lls

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • b a c te r ia , s a liv a r y p r o te in s , d e s q u a m a te d e p ith e lia l c e lls , a n d
le u k o c y te s
M a te r ia a lb a is a s o ft y e llo w o r g r a y - w h ite s tic k y a c c u m u la t io n o f
m ic r o o r g a n is m s , d e s q u a m a t e d e p ith e lia l c e lls , le u k o c y te s , m ix tu r e o f
s a liv a r y p r o te in s a n d lip id s , a n d o c c a s io n a l fo o d d e b r is . It la c k s t h e
o r g a n iz e d s t r u c t u r e t h a t is s e e n in d e n ta l p la q u e . T h e b a c t e r ia a n d th e ir
b y p r o d u c ts p r e s e n t in th e m a te r ia a lb a c a u s e s a n ir r ita tin g e ff e c t o n t h e
g in g iv a .
M a te r ia a lb a d if fe r s fr o m d e n ta l p la q u e in th e f o llo w in g w a y s :

M a te r ia a lb a P la q u e
S o ft, c h e e s e - lik e d e p o s it R e s ilie n t , y e llo w - g r a y d e p o s it

C o m p o s e d o f b a c t e r ia ,
d e s q u a m a t e d e p ith e lia l c e lls ,
le u k o c y te s , m ix tu r e o f s a liv a r y
p r o t e in s a n d lip id s , o c c a s io n a l
fo o d d e b r is , a n d la c k s
g ly c o p r o te in
N o t a c o m p le x a n d o r g a n iz e d
s tr u c tu r e
C o m p o s e d p r im a r ily o f b a c te r ia , m a tr ix o f
s a liv a r y g ly c o p r o te in s , a n d e x t r a c e llu la r
p o ly s a c c h a r id e s
H a s a n o r g a n iz e d s t r u c t u r e a n d is
c o n s id e r e d t o b e a b io film ( a g g lo m e r a tio n
o f m ic r o b ia l c e lls w it h in a m a tr ix o f
e x t r a c e llu la r p o ly m e r ic s u b s t a n c e s lik e
p o ly s a c c h a r id e s , p r o te in s , a n d n u c le ic
a c id s )

It c a n b e e a s ily r e m o v e d w ith a C a n n o t b e r e m o v e d w ith w a t e r s p r a y

w a te r s p r a y d u e t o its t o u g h e x t r a c e llu la r m a tr ix
o ra l c a v ity 275

C a lc u lu s is m a in ly c o m p o s e d o f o r g a n ic m a te r ia l.
It is c o v e r e d b y a la y e r o f b a c te r ia l p la q u e .

• b o th s ta te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• t h e f ir s t s ta te m e n t is tr u e , th e s e c o n d is f a ls e
• t h e f ir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 * th e firs t s ta te m e n t is fa ls e , th e s e c o n d is tru e
C a lc u lu s is d en ta l p laq u e th a t h as u n d e rg o n e m in e ra liz a tio n . It fo rm s o n th e
s u r fa c e s o f n a tu ra l te e th a n d d e n ta l p r o s th e s e s . S a liv a is th e s o u r c e o f m in e r a liz a tio n
fo r s u p ra g in g iv a l c a lc u lu s , w h e r e a s th e s e r u m tr a n s u d a te c a lle d g in g iv a l
c re v ic u la r flu id fu r n is h e s th e m in e r a ls fo r s u b g in g iv a l c a lc u lu s .
• S u p ra g in g iv a l c a lc u lu s : is lo c a te d c o r o n a l to th e g in g iv a l m a r g in . It is u s u a lly
w h ite o r p a le y e llo w in c o lo r a n d is h a r d w ith a c la y lik e c o n s is te n c y . It is e a s ily
re m o v e d b y a p r o fe s s io n a l c le a n in g . T h e tw o m o s t c o m m o n lo c a tio n s fo r
s u p ra g in g iv a l c a lc u lu s to d e v e lo p a re th e b u c c a l s u r fa c e s o f th e m a x illa r y m o la r s
a n d th e lin g u a l s u r fa c e s o f th e m a n d ib u la r a n te r io r te e th . S a liv a fro m th e p a r o tid
g la n d flo w s o v e r th e fa c ia l s u r fa c e s o f th e m a x illa r y m o la r s th r o u g h S te n s e n 's
d u c t, w h e re a s th e o r ific e s o f W h a rto n 's d u c t a n d B a r th o lin 's d u c t e m p ty o n to th e
lin g u a l s u r fa c e s o f th e m a n d ib u la r in c is o r s fr o m th e s u b m a n d ib u la r a n d
s u b lin g u a l g la n d s , r e s p e c tiv e ly .
• S u b g in g iv a l c a lc u lu s : is lo c a te d b e lo w th e c r e s t o f th e m a r g in a l g in g iv a . It is
ty p ic a lly h a r d a n d d e n s e a n d fr e q u e n tly a p p e a rs d a r k b r o w n o r g re e n is h b la c k
(d u e to e x p o s u re to g in g iv a l c r e v ic u la r flu id ) w h ile b e in g fir m ly a tta c h e d to th e
to o th s u rfa c e .
In o rg a n ic c o m p o n e n ts o f c a lc u lu s ( 7 0 - 9 0 % ) : c a lc iu m a n d p h o s p h a te s w ith s m a ll
a m o u n ts o f m a g n e s iu m a n d c a rb o n a te ( th e s e a r e d e r iv e d a lm o s t e n tir e ly fro m
s a liv a ) . H y d r o x y a p a tite a n d flu o rid e a re a ls o p re s e n t.
O rg a n ic c o m p o n e n ts o f c a lc u lu s : m ic ro o r g a n is m s ( s a m e a s p la q u e ), d e s q u a m a te d
e p ith e lia l c e lls , le u k o c y te s , a n d m u c in .
1 . C a lc u lu s is m in e ra lize d p laq u e . It is fo rm e d b y b a th in g th e p la q u e in a
h ig h ly c o n c e n tr a te d s o lu tio n o f c a lc iu m a n d p h o s p h o r u s (i.e ., s a liv a ) .
B a c te r ia l p la q u e c o v e r s th e s u r fa c e o f c a lc u lu s .
2. C a lc u lu s c o n tr ib u te s to p e r io d o n ta l d is e a s e b y s e r v in g a s a c o lle c tio n s ite
fo r m o r e b a c te r ia .
3. Im p o rta n t: A r e d u c tio n in g in g iv a l in fla m m a tio n a n d p r o b in g d e p th s w ith
a g a in in c lin ic a l a tta c h m e n t c a n b e o b s e r v e d a fte r r e m o v a l of
s u b g in g iv a l p la q u e a n d c a lc u lu s .
o ra l c a v it y 276

D e n ta l c a r ie s a r is e fr o m th e c a r io g e n ic b a c te r ia th a t r e s id e w it h in th e
s u p r a g in g iv a l p la q u e , w h e r e a s p e r io d o n ta l d is e a s e o r ig in a te s fro m
th e p e r io d o n to p a th ic b a c te r ia th a t h a r b o r s w ith in th e s u b g in g iv a l
p la q u e .
T h e in o r g a n ic c o m p o n e n ts o f p la q u e a r e p r e d o m in a n tly p ro te in s ,
p o ly s a c c h a r id e s , a n d lip id s .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e

• th e f ir s t s t a t e m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s t a t e m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y H f r d e n t a ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e firs t s ta te m e n t is tru e , th e s e c o n d is fa ls e
D e n ta l p la q u e is a b iofilm . It is c o m p o s e d o f m ic r o o r g a n is m s e n c a s e d w ith in an
in te r c e llu la r m a trix th a t a d h e re s fir m ly to th e in tra o ra l h a rd s u r fa c e s a s w e ll a s to
re m o v a b le a n d fix e d re s to ra tio n s .
D e n ta l p la q u e is c la s s ifie d in to tw o ty p e s : s u p ra g in g iv a l p la q u e (s e e n at o r a b o v e th e
g in g iv a l m a rg in ) a n d s u b g in g iv a l p la q u e (s e e n b e lo w th e g in g iv a l m a rg in ).
P la q u e is c o m p o s e d o f b o th o r g a n ic a n d in o r g a n ic m a te ria ls . T h e in o rg a n ic
c o n s titu e n ts o f p laq u e a re m a in ly c alc iu m a nd p h o s p h o ru s w ith trac e a m o u n t of
m in e rals, in c lu d in g s o d iu m , p o ta s s iu m , an d flu o rid e. T h e o rg a n ic c o m p o n e n ts of
p la q u e a re p o ly s a c c h a rid e s , p ro te in s , g ly c o p ro te in s , lipid m a te ria l, a nd D N A .
D e n ta l p la q u e is c o m p o s e d o f a p p r o x im a te ly 1 0 11 b a c te r ia in 1 g ra m o f p la q u e . D e n ta l
c a rie s a ris e fro m th e c a rio g e n ic b a c te ria th a t re s id e w ith in th e s u p ra g in g iv a l p la qu e,
w h e r e a s p erio d o n tal d is e a s e o r ig in a te s fro m th e p e rio d o n to p a th ic b a c te ria th a t
h a rb o rs w ith in th e s u b g in g iv a l p la qu e.
Streptococcus mutans a n d Streptococcus sobrinus, th e p re d o m in a n t
m ic r o o r g a n is m s th a t c a u s e d e n ta l c a rie s , c o lo n iz e th e s u rfa c e o f th e to o th s o o n a fte r
its e ru p tio n . T h e s e o rg a n is m s h a rb o r w ith in th e s u p ra g in g iv a l p la q u e a n d a re n o t o n ly
a c id o g e n ic (c a p a b le o f p ro d u c in g a c id ) b u t a ls o a c id u r ic (c a p a b le o f g r o w in g a t lo w
p H ). A c id o g e n ic p la q u e b a c te ria p ro m o te to o th d e m in e r a liz a tio n a n d d e c a y by
fe r m e n tin g d ie ta r y s u c ro s e , w h ic h a ls o lo w e rs th e pH o f th e to o th . S. mutans a ls o
p ro d u c e a n e x tr a c e llu la r a d h e s iv e p o ly m e r, g lucan . G lu c a n fa c ilita te s a d h e s io n o f S.
mutans to th e to o th s u rfa c e , p ro m o tin g c a r io g e n e s is in th e u n d e rly in g to o th s tru c tu re s .
M ic r o o r g a n is m s s u c h a s Aggregatibacter actinomycetemcomitans, Porphyromonas
gingivalis, Prevotetla intermedia, Treponema forsythia, Campylobacter rectus, a nd
Treponema denticola a re re s p o n s ib le fo r p e r io d o n ta l d is e a s e , re s id in g m a in ly w ith in
s u b g in g iv a l d e n ta l p la q u e . T h e s e p e rio d o n to p a th ic m ic r o o r g a n is m s p e n e tr a te th e
g in g iv a l e p ith e liu m , c a u s e a n in fla m m a to r y h o s t re s p o n s e , w h ic h le a d s to p e rio d o n ta l
d e s tru c tio n . T h e o u tc o m e is g in g iv a l re c e s s io n (a p ic a l m ig ra tio n of g in g iv a l tis s u e ),
p e rio d o n ta l a tta c h m e n t lo s s , a n d fo r m a tio n o f p e rio d o n ta l p o c k e ts (in c re a s e d d e p th of
g in g iv a l c re v ic e ).
o ra l c a v ity 277

W h ic h o f th e fo llo w in g s ta te m e n ts c o m p a r in g n e c r o tiz in g u lc e r a tiv e

g in g iv it is (N U G ) a n d p r im a r y h e r p e tic g in g iv o s to m a titis is c o r r e c t?

• N U G in v o lv e s th e o r o p h a r y n x a n d th r o a t w h e r e a s h e r p e tic
g in g iv o s to m a titis d o e s n o t
• N U G is a fu s o s p ir o c h a e ta l in fe c t io n w h e r e a s h e r p e tic g in g iv o s to m a titis is
o f v ir a l e tio lo g y
• N U G is a p a in le s s c o n d it io n w h e r e a s h e r p e tic g in g iv o s to m a titis is v e r y
p a in fu l
• N U G is c o m m o n in c h ild r e n w h e r e a s h e r p e tic g in g iv o s to m a titis a f fe c ts
a d u lts

M IC R O B IO L O G Y /P A T H O L O G Y H f r d e n t a ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • NUG is a fu so sp irochaetal infection w h e re as h erp etic g in g ivo s to m atitis is of viral etiology
B o th n e c ro tiz in g u lc e r a tiv e g in g iv itis ( N U G ) a n d p rim a r y h e r p e tic g in g iv o s to m a titis a re p a in fu l
c o n d itio n s , b o th w ith te n d e n c ie s to w a rd g in g iv a l h e m o r rh a g e .
T h e fo llo w in g fe a tu r e s d iffe r e n tia te N U G fr o m p rim a r y h e rp e tic g in g iv o s to m a titis :

N ecrotizing u lcerative gingivitis P rim ary herpetic gin g ivostom atitis

C a u s e d b y th e interaction b e tw e e n bacteria
( s p iro c h e te s , P re v o te lla in te rm e d ia ,
F u s o b a c te riu m , T re p o n e m a , a n d
S e le n o m o n a s ) a n d im paired h ost response
( p r e e x is tin g g in g iv itis , g in g iv a l in ju ry , s m o k in g , C a u s e d b y h e r p e s s im p le x v iru s
Etiology
n u tritio n a l d e fic ie n c y , fa tig u e c a u s e d b y c h r o n ic (H S V ) ty p e 1
s le e p d e p r iv a tio n , a lc o h o l o r d r u g a b u s e ,
p s y c h o s o m a tic f a c to r s s u c h a s s tr e s s , o r
s y s te m ic d is e a s e s u c h a s le u k e m ia , c a n c e r ,
H IV /A ID S )
C h a r a c te riz e d b y th e fo r m a tio n o f c r a te r - lik e C h a ra c te r iz e d b y d iffu s e e ry th e m a o f
d e p r e s s io n s a n d u lc e r s a t th e c r e s t o f th e g in g iv a a n d a ls o in v o lv in g th e
in te r d e n ta l p a p illa e th a t s u b s e q u e n tly p r o g r e s s a d ja c e n t o ra l m u c o s a , s o ft p a la te ,
Clinical to in v o lv e th e m a r g in a l g in g iv a a n d r a r e ly to th e p h a ry n x , s u b lin g u a l m u c o s a , a n d th e
fea tures a tta c h e d g in g iv a a n d o r a l m u c o s a . T h e n e c r o tic to n g u e . In itia lly p r e s e n ts w ith g r a y
tis s u e o f th e g in g iv a is c o v e r e d b y a v e s ic le s th a t r u p tu r e to fo r m s m a ll
p s e u d o m e m b r a n e th a t p e e ls o ff a n d le a v e s th e p a in fu l u lc e r s w ith h a lo - lik e m a rg in s
h e m o r r h a g ic a r e a s . a n d d e p r e s s e d c e n tr a l p o r tio n s .

A ge U n c o m m o n in c h ild r e n O c c u r s m o s t c o m m o n ly in c h ild r e n

C o u rse o f
the N o d e fin ite d u ra tio n 7 to 1 0 d a y s
d isease
Im m unity S o m e d e g r e e o f im m u n ity is c o n fe rr e d
Im m u n ity is n o t c o n fe r r e d
status in a c u te s ta g e s

C o ntagion
N o n c o n ta g io u s C o n ta g io u s
status
in fe c tio n c o n tro l 278

Q u a te r n a r y a m m o n iu m c o m p o u n d s a r e c a tio n ic d e te r g e n ts .
T h e y c a n b e u s e d fo r s k in a n tis e p s is .

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e fir s t s t a t e m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s t a t e m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • b o th s ta te m e n ts a re tru e
D e te r g e n ts a r e “ s u r f a c e - a c t iv e ” a g e n ts c o m p o s e d o f a lo n g - c h a in , lip id - s o lu b le ,
h y d r o p h o b ic p o r tio n a n d a p o la r h y d r o p h ilic g r o u p , w h ic h c a n b e a c a tio n , a n
a n io n , o r a n o n io n ic g r o u p . T h e s e s u r f a c t a n t s in te r a c t w it h t h e lip id in th e cell
m e m b ra n e ( th r o u g h t h e ir h y d r o p h o b ic c h a in ) w ith t h e s u r r o u n d in g w a t e r
th r o u g h t h e ir p o la r g r o u p a n d t h u s d is ru p t th e m e m b ra n e .
Q u a te rn a ry a m m o n iu m c o m p o u n d s ( e . g ., b e n z a lk o n iu m c h lo r id e ) a r e
c a t io n ic d e te r g e n ts . T h e y a r e u s e d a s d is in fe c ta n ts a n d a n tis e p tic s . G r a m ­
p o s itiv e b a c t e r ia a r e t h e m o s t s u s c e p t ib le t o d e s t r u c t io n . T h e s e c o m p o u n d s
a re n o t s p o r ic id a l, tu b e r c u lo c id a l, o r v ir ic id a l a n d a r e in a c tiv a te d b y a n io n ic
d e t e r g e n t s ( s o a p s a n d t h e ir o n in h a r d w a te r ) .
A n io n ic s u rfa c e -a c tin g s u b s t a n c e s in c lu d e s y n t h e t ic a n io n ic d e t e r g e n t s a n d
so ap s. T h e s e s u b s ta n c e s a lt e r th e n a tu r e o f in te r fa c e s t o lo w e r s u r fa c e
te n s io n a n d in c r e a s e c le a n in g . T h e ir p r im a r y v a lu e a p p e a r s t o b e t h e ir a b ilit y to
re m o v e m ic ro o rg a n is m s m e c h a n ic a lly fr o m t h e s k in s u r fa c e .
_ 1. N o n io n ic c h e m ic a ls d o n o t p o s s e s s a n y a n t im ic r o b ia l p r o p e r tie s .
2 . D is in fe c tio n d e s t r o y s a ll th e m ic r o o r g a n is m s in a c e r ta in
e n v ir o n m e n t e x c e p t f o r s p o r e s . T h e r e fo r e , o b je c ts t h a t h a v e b e e n
d is in f e c t e d m a y s till t r a n s m it a p a t h o g e n ic m ic r o o r g a n is m .
S te riliz a tio n , h o w e v e r , is t h e c o m p le t e e lim in a tio n o f a ll o r g a n is m s
in c lu d in g s p o r e s .
3 . A n tis e p tic s a r e g e r m ic id a l s u b s t a n c e s u s e d o n s k in o r o t h e r
livin g tis s u e in a n a t t e m p t t o in h ib it o r d e s t r o y m ic r o o r g a n is m s .
A n t is e p t ic s in c lu d e a lc o h o ls , c h lo r h e x id in e , io d in e , q u a t e r n a r y
a m m o n iu m c o m p o u n d s , a n d tr ic lo s a n .
in fe c tio n c o n tr o l 279

W h ic h of th e fo llo w in g is a p o w e rfu l o x id iz in g a g e n t th a t in a c tiv a te s

b a cteria an d m o s t v iru s e s by o x id iz in g fre e s u lfh y d ry l g ro u p s ?

• a lc o h o l
• c h lo r in e
• f o r m a ld e h y d e
• phenol

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • c h lo rin e
C h lo r in e is th e a c tiv e c o m p o n e n t o f h y p o c h lo rite ( b le a c h ) , w h ic h is u s e d a s a
d is in fe c ta n t.
D is in fe c ta n ts a r e a n t im ic r o b ia l a g e n t s t h a t k ill ( g e r m ic id e ) o r p r e v e n t th e
g r o w th ( m ic r o b io s t a t ic ) o f p a t h o g e n ic m ic r o o r g a n is m s . D is in fe c ta n ts a re n ot
c o n s id e re d s afe fo r u s e o n liv in g tis s u e ( a s o p p o s e d t o a n t is e p t ic s w h ic h
a r e ) a n d a r e a p p lie d o n ly t o in a n im a t e o b je c t s ( c o u n t e r to p s , lig h t h a n d le s ,
h e a d r e s ts , e tc .). D is in f e c t a n t s d o n o t d e s t r o y b a c te r ia l e n d o s p o r e s .
D is in fe c tio n is n o t a s p o t e n t a s s te r iliz a tio n .
1 . P h en o l w a s t h e o r ig in a l d is in f e c t a n t u s e d in h o s p ita ls , b u t is ra re ly
u sed a s a d is in f e c t a n t t o d a y b e c a u s e it is to o c a u s tic .
2 . F o rm a ld e h y d e ( 3 7 % s o lu tio n in w a t e r = F o r m a lin ) d e n a t u r e s
p r o te in a n d n u c le ic a c id s .
3 . C o n c e n tra tio n a n d c o n ta c t tim e a r e c r it ic a l f a c t o r s th a t d e t e r m in e
th e e ff e c t iv e n e s s o f a n a n t im ic r o b ia l a g e n t a g a in s t a p a r t ic u la r
m ic r o o r g a n is m . A n y o r a ll o f th e t h r e e m a jo r p o r t io n s o f m ic r o b ia l
c e lls c a n b e a ff e c te d : th e c e ll m e m b r a n e , c y to p la s m ic c o n te n ts
( p a r tic u la r ly e n z y m e s ) , a n d n u c le a r m a te ria l.
in fe c tio n c o n tro l 280

H o w long d o e s it ta k e to kill b a cteria l e n d o s p o re s w h e n a d en tal

in s tru m e n t is im m ers e d in a c h e m ic al s te rila n t su ch as 2%
g lu ta ra ld e h y d e, h y d ro g e n p e ro xid e or p e ra c e tic acid ?

• 1 0 - 3 0 m in u te s
• 1 -2 h o u rs

• 1 0 - 1 2 h o u rs
• 2 4 h o u rs

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • 1 0-12 h o u rs
2% g lu ta ra ld e h y d e is a n a lk a liz in g a g e n t h ig h ly le t h a l to e s s e n t ia lly a ll
m ic r o o r g a n is m s if s u f f ic ie n t c o n t a c t t im e ( 1 0 h o u r s ) is p r o v id e d w ith a n
a b s e n c e o f e x tr a n e o u s o r g a n ic m a te r ia l. H y d r o g e n p e r o x id e a n d p e r a c e tic a c id
can r e q u ir e u p to 12 h o u rs to s t e r iliz e e q u ip m e n t. N o te: A lc o h o ls ,
c h lo r h e x id in e , a n d q u a t e r n a r y a m m o n iu m c o m p o u n d s a r e d is in f e c t a n t s .
A d v a n ta g e s o f g lu ta r a ld e h y d e s :
• M o s t p o t e n t c a t e g o r y o f c h e m ic a l g e r m ic id e
• C a p a b le o f k illin g s p o r e s ( a ft e r 1 0 h o u r s )
• E P A re g is te re d as an im m e rs io n s te rila n t
• C a n b e u s e d o n h e a t s e n s it iv e m a te r ia ls
D is a d v a n ta g e s o f g lu ta r a ld e h y d e s :
• L o n g p e r io d r e q u ir e d f o r s te r iliz a tio n
• A lle r g e n ic
• N o t a n e n v ir o n m e n t a l d is in f e c t a n t
• E x tr e m e ly t o x ic to tis s u e s
R e m e m b e r: In h o s p ita ls , g lu t a r a ld e h y d e s a r e u s e d t o s te r iliz e r e s p ir a to r y
t h e r a p y e q u ip m e n t.
in fe c tio n c o n tro l 281

T h e e ffe c tive n e s s o f a u to c la v in g is b e st d e te rm in e d by c u ltu rin g

b a cteria l s po res.
S p o re te s tin g o f a u to c la v e u n its is re c o m m e n d e d m o n th ly .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e fir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e firs t s ta te m e n t is tru e , th e s e c o n d is fa ls e
M o is t h e a t d e s tro y s b a c te ria b y d e n a t u r a t io n o f th e h ig h p r o t e in - c o n t a in in g
b a c te r ia . T h e a u t o c la v e p r o v id e s s te r iliz a tio n w h e n u s e d a t 2 5 0 ° F ( 1 2 1 ° C ) fo r
1 5 - 2 0 m in u t e s b e c a u s e it a p p lie s t h e h e a t u n d e r p r e s s u r e , w h ic h g r e a tly
s p e e d s u p th e d e n a t u r a t io n p r o c e s s w h e n c o m p a r e d w ith b o ilin g w a te r .
U s u a lly o n ly 1 0 m in u te s is r e q u ir e d to d e s t r o y a ll o f t h e b a c te r ia , b u t th e
in c r e a s e d t im e is a llo w e d f o r p e n e tr a tio n w h e n t h e in s tr u m e n ts a r e w r a p p e d in
t h ic k t o w e ls . T h e s e c o n d it io n s w ill y ie ld 15 lbs. p re s s u re o f s team p e r s q u a r e
in c h .
_ 1. T h e e ff e c tiv e n e s s o f a u to c la v in g is b e s t d e te rm in e d b y c u ltu rin g
b a c te ria l s p o res .
2 . S p o r e te s tin g o f a u t o c la v e u n it s is re c o m m e n d e d w e e k ly .
3. P re c le a n in g is th e m o s t im p o rta n t s te p in in s tru m e n t
s te riliz a tio n . D e b r is a c ts a s a b a r r ie r t o th e s t e r ila n t a n d
s te r iliz a tio n p r o c e s s .
4. U ltra s o n ic in s tru m e n t c le a n in g is th e s a fe s t a n d m o s t e ff ic a c io u s
m e th o d o f p r e c le a n in g .
in fe c tio n c o n tr o l 282

T h e p ro p e r tim e a n d te m p e ra tu re fo r d ry h eat s te riliz a tio n is:

• 3 2 0 ° F (1 6 0 °C ) fo r 2 h o u rs
• 2 5 0 ° F (1 2 1 ° C ) f o r 2 0 - 3 0 m in u te s

• 4 5 0 ° F ( 2 3 2 ° C ) f o r 5 m in u te s
• 8 9 ° F (31 ° C ) f o r 3 0 m in u te s

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 3 2 0 °F (1 6 0 °C ) fo r 2 h o u rs
N o te: 3 4 0 ° F ( 1 7 0 ° C ) f o r 1 h o u r is a ls o e ff e c tiv e .
It e m s w h ic h a r e u s u a lly s t e r iliz e d b y d r y h e a t c a n b e a u to c la v e d . T h e y s h o u ld
b e r e m o v e d im m e d ia t e ly a f t e r c y c le t o d im in is h th e p o s s ib ilit y o f c o r r o s io n o f
th e in s t r u m e n t s a n d d u llin g o f s h a rp p o in t s o r e d g e s (c a rb o n s te e l
in s t r u m e n t s ) . D ry h e a t d e s tro y s m ic ro o rg a n is m s by c a u s in g c o a g u la tio n
o f p ro tein s .
A d v a n ta g e s o f d r y h e a t:
• E ffe c tiv e a n d s a fe f o r s t e r iliz a t io n o f m e ta l in s tr u m e n ts
• D o e s n o t d u ll o r c o r r o d e in s t r u m e n t s
D is a d v a n ta g e s o f d r y h e a t:
• L o n g c y c le
• P o o r p e n e tr a tio n
• W ill r u in h e a t - s e n s it iv e m a te r ia ls
Im p o r ta n t: I n s t r u m e n t s m u s t be d ry b e fo r e b o th d r y h e a t s t e r iliz a t io n a n d
e t h y le n e o x id e s te r iliz a tio n . W a te r w ill in te rfe re w ith th e s te riliz a tio n
p ro c es s.
in fe c tio n c o n tro l 283

W h ic h o n e of th e fo llo w in g is N O T c o n s id e re d as th e p a ra m e te r fo r
th e e ffe c tive n e s s of m o ist h eat s te riliza tio n ?

• t e m p e r a tu r e
• p u r e s a tu r a te d s te a m
• e x p o s u r e tim e
• r e la t iv e h u m id it y

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a ri I • V o lu m e 13 • © 2 0 1 7
 • re la tiv e h u m id ity
M o is t h e a t s t e r iliz a t io n w o r k s b y c r e a t in g a n in c r e a s e d t e m p e r a t u r e o f
s a t u r a t e d s te a m u n d e r p r e s s u r e . M o is t h e a t s t e r iliz a t io n is b e s t a c c o m p lis h e d
in a n a u t o c la v e ( a s o p h is t ic a t e d p r e s s u r e c o o k e r ) . M o is t h e a t d e s t r o y s
m ic r o o r g a n is m s b y ir r e v e r s ib le d e n a tu ra tio n o f b a c te ria l p ro te in an d
d is ru p tin g h y d ro g e n b o n d s b e tw e e n p e p tid e g ro u p s .
T h e m a jo r p a r a m e t e r s o f s te a m s te r iliz a tio n a re :
1. S te a m : T h e r e c o m m e n d e d s te a m f o r s t e r iliz a t io n is d ry p u re s a tu ra te d
s te a m ( d r y n e s s fr a c tio n > 9 7 % ) . T h e e f f e c t iv e n e s s o f a n a u t o c la v e d e p e n d s
o n t h e p e n e t r a t io n o f s te a m in to th e m a t e r ia ls t o b e s t e r iliz e d ( d e t e r m in e d
b y s iz e a n d d e n s it y o f th e m a te r ia l p la c e d a n d fl o w r a te o f s te a m ) , a b s e n c e
o f a ir , a n d d u r a tio n o f e x p o s u r e .
2 . P re s s u re : M o is t h e a t in th e fo r m o f p r e s s u r iz e d s te a m e le v a t e s th e
t e m p e r a t u r e th a t w ill k ill a ll th e m ic r o o r g a n is m s a n d t h e ir s p o r e s . O n
r e m o v a l o f a ir f r o m th e a u to c la v e , th e c h a m b e r t e m p e r a t u r e b e c o m e s
d ir e c t ly p r o p o r t io n a l t o th e s te a m p r e s s u r e . U n d e r t h e s e c o n d it io n s , s p o r e s
a r e k ille d in le s s t h a n 5 m in u te s .
3 . T e m p e r a tu r e : A s p e c if ic t e m p e r a t u r e s h o u ld b e m a in t a in e d to k ill th e
m ic r o o r g a n is m s in m in im a l tim e . T h e r e c o m m e n d e d c o m m o n s te a m
s t e r iliz in g t e m p e r a t u r e s a r e 1 2 1 ° C a n d 1 3 2 ° C .
4 . E x p o s u re tim e: M in im u m e x p o s u r e p e r io d f o r s t e r iliz a t io n o f w r a p p e d
o b je c t s a r e 3 0 m in u t e s a t 1 2 1 ° C in a g r a v it y d is p la c e m e n t a u t o c la v e o r 4
m in u t e s a t 1 3 2 ° C in a h ig h s p e e d p r e v a c u u m s te r iliz e r .
T o m o n it o r th e e ff e c t iv e n e s s o f s te r iliz a tio n , Bacillus stearothermophilus
s p o r e s a r e p la c e d in th e c e n t e r o f th e a u to c la v e a s a b io lo g ic a l in d ic a to r . A t th e
e n d o f s te r iliz a tio n , t h e s e s p o r e s a r e k ille d , t h e r e f o r e u n a b le to g r o w w h e n
in c u b a te d a t 3 7 ° C , d e t e r m in in g t h e s u c c e s s o f s t e r iliz a t io n .
in fe c tio n c o n tr o l 284

E th y len e o x id e s te riliz a tio n is fa s te r th a n a m o is t h eat a u to c lav e .

E th y len e o x id e s te riliz a tio n can be u sed to s te riliz e h eat s e n s itiv e
in s tru m en ts.

• b o th s ta te m e n ts a r e tr u e
• b o th s t a te m e n ts a r e fa ls e
• th e fir s t s t a te m e n t is tr u e , th e s e c o n d is fa ls e
• th e fir s t s t a te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y iM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tru e
S t e r iliz a t io n w it h e t h y le n e o x id e is a s lo w p r o c e s s ( 1 0 - 1 6 h o u r s ) d e p e n d in g o n
th e m a te r ia l t o b e s te r iliz e d . E th y le n e o x id e g a s h a s b e e n w id e ly u s e d a s a
s t e r iliz a t io n a g e n t, p a r tic u la r ly f o r p r e p a c k a g e d , d is p o s a b le p la s tic w a r e in
h o s p ita ls . T h is g a s is v e ry to x ic t o h u m a n s a n d is a ls o fla m m a b le , m a k in g
its g e n e ra l u s e lim ite d . E x p o s u r e o f m a t e r ia ls t o e t h y le n e g a s m u s t b e
p e r f o r m e d in s p e c ia l s e a le d c h a m b e r s . I te m s m u s t b e c le a n e d a n d d r ie d
t h o r o u g h ly b e fo r e th e s t e r iliz a t io n p r o c e s s .
A d v a n ta g e s o f e th y le n e o x id e s te r iliz a tio n :
• H ig h ly p e n e tr a tiv e
• D o e s n o t d a m a g e h e a t - la b ile m a t e r ia ls ( r u b b e r , c o tt o n , p la s tic , e tc .)
• E v a p o r a te s w ith o u t le a v in g a r e s id u e
• W o r k s w e ll f o r m a t e r ia ls th a t c a n n o t b e e x p o s e d t o m o is tu r e
Im p o r ta n t: E th y le n e o x id e f u n c t io n s a s a n a lk y la t in g a g e n t b y irre v e rs ib ly
in a c tiv a tin g c e llu la r n u c le ic a c id s ( D N A ) a n d p r o te in s .
in fe c tio n c o n tr o l 285

T h e k illin g o r r e m o v a l o f a ll m ic r o o r g a n is m s , in c lu d in g
b a c te r ia l s p o r e s , is c a lle d :

• d is in fe c tio n
• c le a n in g
• s te r iliz a t io n
• w ip in g

M IC R O B IO L O G Y /P A T H O L O G Y !* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • s te r iliz a tio n - r e fe r s to th e a b s e n c e o f a ll liv in g fo r m s
D is in fe c tio n is th e k illin g o f m a n y , b u t n o t a ll, m ic r o o r g a n is m s . It d o e s n o t
in c lu d e th e d e s tr u c tio n o f s p o r e s . T h e t e r m “d is in f e c t a n t ” is r e s e r v e d fo r
c h e m ic a ls a p p lie d t o in a n im a t e s u r f a c e s ( la b to p s , c o u n t e r to p s , h e a d r e s ts ,
lig h t h a n d le s , e t c . ) . T h e y a r e n o t c o n s id e r e d s a fe f o r u s e o n liv in g tis s u e .
A n tis e p tic s a r e c h e m ic a l a g e n t s s im ila r t o d is in f e c t a n t s , b u t t h e y m a y b e
a p p lie d s a f e ly t o liv in g tis s u e . N o te : S o a p o n ly r e m o v e s m ic r o o r g a n is m s .
Im p o r ta n t: R e m e m b e r th e d o c tr in e o f s te r iliz a t io n - D o n o t d is in f e c t w h a t
y o u c a n s te r iliz e !
1. T h e im m e r s io n o f d e n ta l in s t r u m e n t s in c o ld d is in f e c t a n t s w ill n o t
d e s tr o y s p o r e s o r th e h e p a t it is v ir u s e s - t h e y a r e r e s is ta n t to
p h y s ic a l a n d c h e m ic a l a g e n ts .
2 . L iq u id s a r e g e n e r a lly s te r iliz e d b y f iltr a tio n . T h e m o s t c o m m o n ly
u s e d f ilt e r is c o m p o s e d o f n it r o c e llu lo s e a n d h a s a p o r e s iz e o f
0 .2 2 p m . T h is s iz e w ill r e ta in a ll b a c t e r ia a n d s p o r e s .
3 . F ilte r s w o r k b y p h y s ic a lly tr a p p in g p a r tic le s la r g e r t h a n th e p o r e
s iz e .
in fe c tio n c o n tro l 286

A ll o f th e fo llo w in g a r e a d v a n ta g e s o f u s in g a lc o h o ls (7 0 % is o p ro p y l
a n d 7 0 % e th y l a lc o h o l) a s s u r fa c e d is in fe c ta n ts E X C E P T o n e . W h ic h
o n e is th e E X C E P T IO N ?

• th e y a r e b a c te r ic id a l
• th e y a r e s p o r ic id a l
• th e y a r e tu b e r c u lo c id a l
• th e y a r e e c o n o m ic a l

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a rt I - V o l u m e 1 3 - © 2 0 1 7
 th e y a r e s p o r ic id a l
* * * T h is is fa ls e ; th e y a r e n o t s p o r ic id a l.
A lc o h o l is p r o b a b ly t h e m o s t w id e ly u s e d a n t is e p t ic a n d is u s e d t o r e d u c e
th e n u m b e r o f m ic r o o r g a n is m s o n t h e s k in s u r f a c e in t h e a r e a o f a w o u n d .
A lc o h o l d e n a tu r e s p r o te in s , e x t r a c t s m e m b r a n e lip id s a n d a c t s a s a
d e h y d r a t in g a g e n t, a ll o f w h ic h c o n t r ib u t e t o its e ff e c t iv e n e s s a s a n a n tis e p tic .
E v e n s o m e v ir u s e s ( lip o p h ilic v ir u s e s o n ly ) a r e in a c tiv a te d b y a lc o h o l. T h e
d r a w b a c k s o f a lc o h o l a r e t h a t it e v a p o r a t e s t o o q u ic k ly a n d h a s d im in is h e d
a c t iv it y a g a in s t v ir u s e s in d r ie d b lo o d , s a liv a , a n d o t h e r s e c r e t io n s o n s u r fa c e s
( th is is d u e t o t h e p r e s e n c e o f t is s u e p r o te in s a n d g ly c o p r o t e in s w h ic h r e n d e r
a lc o h o l in e ffe c tiv e ) .
F o r th e a b o v e r e a s o n , a lc o h o ls a r e n o t r e g a r d e d a s e ff e c tiv e s u r fa c e
c le a n s in g a g e n t s ( i.e ., c le a n in g a d e n ta l o p e r a t o r y f o llo w in g p a t ie n t t r e a tm e n t) .
1 . Is o p r o p y l a lc o h o l ( 9 0 % - 9 5 % ) is t h e m a jo r fo r m in u s e in
h o s p it a ls .
2 . E th a n o l ( 7 0 % ) is w id e ly u s e d to c le a n t h e s k in p r io r to
im m u n iz a t io n o r v e n ip u n c t u r e .
3 . Io d in e is t h e m o s t e ffe c t iv e s k in a n tis e p tic u s e d in m e d ic a l
p r a c tic e . It a c ts a s a n o x id iz in g a g e n t a n d c o m b in e s ir r e v e r s ib ly
w ith p r o te in s .
in fe c tio n c o n tro l 287

T h e g r e a te s t o c c u p a tio n a l h e a lth c a re w o r k e r r is k fo r b io o d b o r n e
in fe c tio n is:

• h e p a titis C v ir u s
• h u m a n im m u n o d e fic ie n c y v ir u s
• h e p a tit is B v ir u s
• tu b e r c u lo s is

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • h e p a titis B v ir u s
T h e b a s is o f th e c u r r e n t s ta n d a r d ( fo r m e r ly “ u n iv e r s a l” ) in fe c tio n c o n tr o l
p r e c a u t io n s w a s f ir s t r e c o m m e n d e d b y th e C D C in 1 9 8 7 . T h e p u r p o s e w a s to
p r o te c t h e a lth c a r e w o r k e r s ( H C W ) fr o m o c c u p a t io n a l t r a n s m is s io n o f a ll
b lo o d b o r n e in fe c tio u s d is e a s e s d u r in g p r o v is io n o f p a tie n t c a r e . W h ile m a n y
h e a lth p r o f e s s io n a ls fo c u s e d o n t h e H u m a n im m u n o d e f ic ie n c y V ir u s ( H IV ) a s
t h e m a jo r r is k , a c c u m u la t e d e v id e n c e c le a r ly d e m o n s t r a t e d t h a t th e h e p a t it is B
v ir u s ( H B V ) w a s r e s p o n s ib le f o r in fe c tio n in 1 0 % - 3 0 % o f e x p o s e d , s u s c e p t ib le
H C W . C o n c e n t r a t io n s o f H B V in th e b lo o d o f a c h r o n ic c a r r ie r c a n r a n g e
b e t w e e n 1 , 0 0 0 , 0 0 0 t o 1 0 0 , 0 0 0 , 0 0 0 v ir io n s p e r m l_, in c o n t r a s t t o s ig n if ic a n t ly
lo w e r v ir a l lo a d s d e m o n s t r a t e d f o r b o th H I V - in f e c t e d p e r s o n s a n d p e r s o n s w it h
A ID S .
V ir a l c o n c e n t r a t io n s d e t e c t e d in h e p a t it is C v ir u s ( H C V ) in fe c te d in d iv id u a ls
r a n g e b e t w e e n th o s e n o te d f o r H B V a n d H IV . T h u s , w e t a r g e t th e m o s t
in fe c tio u s b lo o d b o r n e p a th o g e n w it h o u r in fe c tio n c o n t r o l s ta n d a r d s .
P r e c a u t io n s t h a t m in im iz e p o te n tia l H B V s p r e a d , a ls o b y in fe r e n c e , p r e v e n t
c r o s s - in f e c t io n o f le s s in fe c tio u s m ic r o o r g a n is m s .
_ 1. R e m e m b e r : S e m e n , s e r u m , a m n io t ic f lu id a n d b r e a s t m ilk a r e
f lu id s t h a t c a n t r a n s m it H IV . A c c u m u la t in g e v id e n c e s u g g e s t s t h a t
H IV is n o t t r a n s m it t e d b y c a s u a l h o u s e h o ld o r s o c ia l c o n ta c t.
2 . Im p o r ta n t: C o n t a c t w it h s a liv a , te a r s , o r s w e a t h a s n e v e r b e e n
s h o w n t o r e s u lt in t r a n s m is s io n o f H IV .
in fe c tio n c o n tro l 288

F o r e a c h n u m b e r e d d e fin it io n b e lo w , s e le c t th e m o s t c lo s e ly lin k e d
te r m fr o m th e lis t p ro v id e d .

1. A n a b ilit y to in d u c e a d is e a s e . A . R e s e r v o ir
2 . A n y m ic r o o r g a n is m c a p a b le o f B . In fe c tio n s o u r c e
c a u s in g in fe c t io n . C . P a th o g e n ic it y
3 . A s ite w h e r e th e m ic r o o r g a n is m s D . In fe c tio u s v e c to r
r e s id e a n d m u ltip ly .
E . I n fe c tin g d o s e
4 . T h e n u m b e r o f m ic r o o r g a n is m s
a v a ila b le to in d u c e d is e a s e .
5. T h e s ite fr o m w h e r e th e in fe c t io n is
t r a n s m itt e d to a s u s c e p tib le h o s t.

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • 1. C , 2. D, 3 . A , 4. E, 5. B
A n in fe c tio n is tr a n s m it te d d e p e n d in g o n th r e e e le m e n ts t h a t a r e in t e r c o n n e c te d ,
i.e ., c a u s a tiv e a g e n t, s o u r c e , a n d m o d e o f tr a n s m is s io n .
A m ic r o o r g a n is m th a t is c a p a b le o f c a u s in g in fe c tio n is k n o w n a s a n in fe c tio u s
v e c to r.
A n im p o r ta n t p r o p e r ty o f a c a u s a tiv e a g e n t is p a th o g e n ic it y , w h ic h d e te r m in e s
th e e x te n t to w h ic h a n a g e n t is c a p a b le o f p r o d u c in g d is e a s e in a n in fe c te d
p o p u la tio n .
N u m b e r o f p e r s o n s in w h o m
c lin ic a l d is e a s e d e v e lo p s
P a t h o g e n ic ity o f a n a g e n t = ------------- ------------- — ------ -
N u m b e r o f p e r s o n s in fe c te d

T h e p a th o g e n ic it y o f a n o r g a n is m is c h a r a c te r iz e d b y its v ir u le n t n a tu re , i.e .,
in fe c t io n s e v e r ity , w h ic h is d e te r m in e d b y m o r b id ity a n d m o r ta lity r a te s o f g e r m s
a n d b y th e le v e l o f in v a s iv e n e s s , i.e ., th e c a p a b ility o f a n o r g a n is m to in v a d e
tis s u e s . T y p h o id b a c illi, r a b ie s , m e a s le s , v a r ic e lla , a n d r h in o v ir u s e s s h o w h ig h
p a th o g e n ic ity . In te r m e d ia te p a th o g e n ic it y is s h o w n b y r u b e lla , m u m p s , a n d
a d e n o v ir u s e s , w h ile th e p o lio v ir u s a n d tu b e r c le b a c illu s s h o w lo w p a th o g e n ic ity .
F a c to r s t h a t in c r e a s e th e r is k o f in fe c t io n a r e a s fo llo w s :
1. In fe c tin g d o s e is th e n u m b e r o f o r g a n is m s o r p a th o g e n s r e q u ir e d to c a u s e
a n in fe c tio n .
2 . R e s e r v o ir is th e s ite th a t h a r b o r s th e m ic r o o r g a n is m s , a llo w in g th e m to
m u ltip ly . T h u s , c o n tr o llin g a n a g e n t in its r e s e r v o ir r e d u c e s th e o c c u r r e n c e o f
a d is e a s e . F o r e x a m p le , c h lo r in a tio n o f w a te r a n d p a s te u r iz a tio n o f m ilk
c a u s e s th e d e a t h o f a n a g e n t in its r e s e r v o ir .
3 . In fe c tio n s o u rc e is th e s ite fr o m w h e r e in f e c tio n is tr a n s m it te d to a h o s t
t h r o u g h a n in te r m e d ia r y o b je c t e it h e r d ir e c tly o r in d ir e c tly . In f e c tio n a r is in g
fr o m a p a th o g e n t h a t is tr a n s p o r te d fr o m a n e x te r n a l s o u r c e to th e h o s t is
c a lle d a s e x o g e n o u s in fe c t io n . If th e s o u r c e o f a p a th o g e n is w ith in th e b o d y ,
th e in fe c tio n is c a lle d a n e n d o g e n o u s in fe c tio n .
in fe c tio n c o n tro l 289

W h ic h o f th e fo llo w in g a n tis e p tic s d o e s N O T e x h ib it p e r s is te n t

a c tiv it y ?

• is o p r o p y l a lc o h o l
• c h lo r h e x id in e g lu c o n a te
• tr ic lo s a n
• q u a t e r n a r y a m m o n iu m c o m p o u n d s

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • is o p r o p y l a lc o h o l
P e r s is te n t a c tiv ity ( p r e v io u s ly k n o w n a s r e s id u a l a c tiv it y ) is th e a b ilit y o f a
s u b s t a n c e to p r e v e n t o r in h ib it t h e p r o life r a tio n o r s u r v iv a l o f m ic r o o r g a n is m s
a f t e r t h e s u b s t a n c e h a s b e e n a p p lie d . P e r s is t e n t a c t iv it y c a n la s t f o r m in u t e s to
h o u r s . C h lo r h e x id in e , q u a t e r n a r y a m m o n iu m c o m p o u n d s , o c t e n id in e a n d
tr ic lo s a n a ll e x h ib it p e r s is te n t a c tiv ity . Is o p r o p y l a lc o h o l d o e s n o t in h e r e n tly
e x h ib it p e r s is t e n t a c tiv ity , b u t s o m e a lc o h o l- b a s e d a n t is e p t ic s c a n in c lu d e
a n o t h e r a d d it iv e t h a t p o s s e s s e s th e c h a r a c te r is tic .
N o te : Is o p r o p y l a lc o h o l, w h e n u s e d f o r h a n d a n t is e p s is d o e s n o t r e q u ir e th e
u s e o f w a te r , a n d th u s is a fo r m o f w a te r le s s h a n d h y g ie n e .
in fe c tio n c o n tro l 290

B a c te r ic id a l a g e n ts w o r k b e s t d u rin g w h ic h o f th e fo llo w in g p h a s e s o f
b a c te r ia l g r o w th ?

• la g p h a s e
• lo g p h a s e
• s ta tio n a r y p h a s e
• d e a th p h a s e

M IC R O B IO L O G Y /P A T H O L O G Y d ^ d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • lo g p h a s e
T h e u s e o f b a c te r ic id a l c h e m ic a ls is p r e fe r a b le t o th o s e w h ic h a r e “ s t a t ic .”
T h e la t t e r d o n o t d ir e c t ly k ill o r in a c tiv a te m ic r o b e s , b u t in s te a d in h ib it th e ir
m e t a b o lis m a n d r e p lic a tio n . T h e s e a f f e c t e d o r g a n is m s c a n r e m a in v ia b le b u t
in a c tiv e f o r e x te n d e d in te r v a ls . A p p lic a tio n o f “c id a l” a g e n t s o r p r o c e s s e s a r e
d e s ig n e d t o e n s u r e m ic r o b ia l in a c tiv a tio n .
in fe c tio n c o n tro l 291

T h e m a r k e r m ic r o o r g a n is m fo r in te r m e d ia te s u r fa c e d is in fe c tio n is:

• Bacillus stearothermophilus
• Pseudomonas aeruginosa
• h e p a titis B v ir u s
• Mycobacterium tuberculosis

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 Mycobacterium tuberculosis
•
Mycobacterium tuberculosis is r e c o g n iz e d a s
A n t im ic r o b ia l a c t iv it y a g a in s t
a s ig n if ic a n t b e n c h m a rk c r ite r io n f o r d is in f e c t a n t e ff e c tiv e n e s s . W h ile
tu b e r c u lo s is is n o t t r a n s m it t e d v ia in a n im a te e n v ir o n m e n t a l s u r fa c e s , th e
m o r p h o lo g y a n d s t r u c t u r e o f th e t u b e r c le b a c illi m a k e th e m r e la tiv e ly r e s is ta n t
to p e n e tr a tio n b y a n u m b e r o f lo w - le v e l d is in f e c t a n t c h e m ic a ls .
In te r m e d ia t e - le v e l a g e n ts , s u c h a s p h e n o ls , io d o p h o r s , h y p o c h lo r ite , a n d
c e r ta in p r e p a r a t io n s c o n ta in in g a lc o h o ls p lu s o t h e r c le a n e r d is in f e c t a n t
c h e m ic a ls a r e a b le to p e n e tr a te t h e w a x a n d lip id o u t e r la y e r s s u r r o u n d in g
m y c o b a c te r ia .
in fe c tio n c o n tro l 292

T h e a n tig e n s m o s t r e s p o n s ib le fo r a n im m e d ia te T y p e I r e a c tio n to
n a tu r a l r u b b e r la te x a re :

• p r o t e in s
• a c c e le r a to r s
• c o rn s ta rc h p o w d e rs
• a n ti- o x id a n ts

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a r t I - V o lu m e 1 3 - © 2 0 1 7
 • p r o te in s
O n ly a f e w o f t h e m o r e t h a n 2 5 0 p r o t e in s f o u n d in t h e s a p fr o m t h e r u b b e r tr e e
H e v e a b r a s ilie n s is a r e r e s p o n s ib le f o r c a u s in g th e T y p e I, im m e d ia te , Ig E -
m e d ia te d r e a c tio n s t o n a tu r a l r u b b e r la t e x . T h e s e a r e w a t e r - s o lu b le
m a c r o m o le c u le s th a t c a n le a c h o u t o f la te x g lo v e s w h e n a p e r s o n p e r s p ir e s , o r
b e d e t e c t e d o n t h e s u r f a c e s o f o t h e r p r o d u c t s c o n t a in in g n a tu r a l r u b b e r la t e x
(N R L ).
in fe c tio n c o n tr o l 293

C le a n in g s u r fa c e s p r io r to d is in fe c tio n in c lin ic a l s e ttin g s is re q u ir e d

to :

• d e s tr o y a ll p a th o g e n s
• in h ib it p a t h o g e n g r o w th
• r e d u c e th e c o n c e n tr a tio n o f p a th o g e n s
• w e a k e n th e v ir u le n c e o f p a th o g e n s

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • r e d u c e t h e c o n c e n tr a tio n o f p a th o g e n s
T h e s im p le s t w a y to a p p r o a c h e n v ir o n m e n t a l s u r f a c e d is in f e c t io n is t o a d h e r e
t o a b a s ic p r e m is e o f a s e p tic t e c h n iq u e - c le a n it fir s t. A ll d is in f e c t a n t
p r o d u c ts in c lu d e s p e c if ic la b e l in s t r u c t io n s f o r c le a n in g p r io r to d is in fe c tio n .
C le a n in g is d e fin e d a s t h e p h y s ic a l r e m o v a l o f d e b r is .
T w o e ffe c ts r e s u lt fr o m e f f ic ie n t c le a n in g :
1. A r e d u c tio n in t h e n u m b e r o f m ic r o o r g a n is m s p r e s e n t.
2 . T h e r e m o v a l o f b lo o d , t is s u e b io b u r d e n , a n d o t h e r d e b r is w h ic h can
in te r fe r e w it h d is in fe c tio n .
in fe c tio n c o n tro l 294

T h e m o s t e ffic ie n t w a y to k ill m ic r o b e s is:

• c o ld s te r iliz a tio n
• p r o p e r h a n d w a s h in g w ith s te r iliz in g a n tis e p tic s
• h e a t s t e r iliz a tio n
• im m e r s io n o f c o n ta m in a te d ite m s in c h e m ic a l s te r ila n ts

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • h e a t s te r iliz a tio n
T h e u s e o f h e a t h a s lo n g b e e n r e c o g n iz e d a s t h e m o s t e ffic ie n t, r e lia b le ,
b io lo g ic a lly m o n ito r a b le m e th o d o f s te r iliz a tio n . D u r in g a r o u tin e c y c le
u s in g a n a u to c la v e , u n s a tu r a te d c h e m ic a l v a p o r s te r iliz e r , o r d r y h e a t u n it, c e ll
d e a th is a c c o m p lis h e d v ia h e a t in a c tiv a tio n o f c r itic a l e n z y m e s a n d o th e r
p r o te in s w ith in m ic r o b ia l c e lls .
T h e r e c o m m e n d a t io n s ta tin g t h a t a ll r e u s a b le ite m s t h a t c o m e in c o n t a c t w ith
a p a tie n t's b lo o d , s a liv a , o r m u c o u s m e m b r a n e s m u s t b e s te r iliz e d u s in g
h e a t is n o w r o u tin e ly a c c e p te d a n d u s e d in d e n ta l fa c ilitie s .
in fe c tio n c o n tr o l 295

T h e m o s t c o m m o n fo r m o f a n a d v e r s e e p ith e lia l r e a c tio n n o te d fo r

h e a lth c a r e p r o fe s s io n a ls is:

• ir r ita tio n d e r m a titis

• ty p e I im m e d ia te la te x a lle r g y
• ty p e IV , d e la y e d la te x a lle r g y
• s u p e r fic ia l fu n g a l in fe c tio n s o n th e fin g e r s

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • ©2 0 1 7
 • ir r ita tio n d e r m a titis
A n u m b e r o f p u b lis h e d r e p o r ts h a v e c it e d d a t a s u g g e s t in g t h a t b e tw e e n 2 0 %
a n d 3 0 % o f h e a lth c a r e w o r k e r s s u f f e r fr o m o c c a s io n a l o r c h r o n ic d e r m a titis
o n t h e ir h a n d s . T h e m o s t c o m m o n m a n if e s t a t io n o f th e c o n d it io n is ir r it a tio n
d e r m a titis , a n o n -s p e c ific im m u n e r e a c tio n o ft e n c a u s e d b y c o n t a c t w it h a
s u b s t a n c e t h a t p h y s ic a lly o r c h e m ic a lly d a m a g e s t h e s k in .
T h e c o n d it io n c a n b e a g g r a v a t e d b y fr e q u e n t h a n d w a s h in g , r e s id u a l g lo v e
p o w d e r le f t o n h a n d s , a n d t h e h a r s h n e s s o f r e p e a te d u s e o f s o m e a n t is e p t ic
h a n d w a s h a g e n ts . H e a lth c a r e w o r k e r s lo c a te d in c o ld e r c lim a t e s m a y a ls o
e x p e r ie n c e c h a p p in g d u r in g th e w in t e r m o n th s .
in fe c tio n c o n tr o l 296

A p a tie n t d e v e lo p s a T y p e I, im m e d ia te a lle r g ic r e a c tio n to la te x .

W h e n tr e a tin g h im a n d w e a r in g g lo v e s fr o m n o w o n , y o u c a n :

• w e a r v in y l o r n itr ile g lo v e s
• w e a r h y p o a lle r g e n ic la te x g lo v e s
• g e t a n e x e m p tio n a n d n o t w e a r g lo v e s
• r e f u s e to tr e a t h im

M IC R O B IO L O G Y /P A T H O L O G Y @ M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • w e a r v in y l o r n itr ile g lo v e s
A w id e v a r ie t y o f la te x - a lte r n a tiv e in fe c tio n c o n tr o l it e m s h a v e a p p e a r e d in th e
m a r k e t p la c e w it h in th e la s t 1 0 y e a r s . T h e m o s t w id e ly r e c o g n iz e d a r e n e w e r
g e n e r a t io n s o f v in y l o r n it r ile g lo v e s w h ic h d o n o t c r o s s -r e a c t w it h la te x
a lle r g e n s . P r o d u c ts w it h th e d e s ig n a t io n " h y p o a lle r g e n ic " a r e n o lo n g e r t o b e
la b e le d la t e x a lte r n a tiv e s , a s t h e y c o n ta in la t e x w it h a c h e m ic a l c o a tin g o v e r
th e la te x .
N o te : S t u d ie s o v e r r e c e n t y e a r s h a v e s h o w n th a t n o t a ll la t e x - a lle r g ic p e r s o n s
a r e a b le to u s e h y p o a lle r g e n ic g lo v e s , s in c e m a n y T y p e I a lle r g ic in d iv id u a ls
s till d e v e lo p a lle r g ic m a n if e s t a t io n s w h e n u s in g t h e s e g lo v e s .
in fe c tio n c o n tr o l 297

W h ic h o f th e fo llo w in g is th e p r o c e s s o f k illin g a ll m ic r o o r g a n is m s on
a n o b je c t o r in a m a te r ia l?

• s t a n d a r d iz a tio n
• s a n itiz a tio n
• d is in fe c tio n
• s te r iliz a t io n

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t i • V o lu m e 1 3 • © 2 0 1 7
 • s te r iliz a tio n
S a n itiz a tio n is a p a r t ic u la r k in d o f a n t im ic r o b ia l t r e a t m e n t t h a t lo w e r s t h e to ta l
m ic r o b ia l lo a d to s a fe p u b lic h e a lt h le v e ls .
D is in fe c tio n is t h e p ro c e s s of r e d u c in g th e n u m b e rs of o r in h ib it in g th e
g r o w th o f m ic r o o r g a n is m s , e s p e c ia lly p a th o g e n s , t o t h e p o in t w h e r e t h e y n o
lo n g e r p o s e a t h r e a t o f d is e a s e .
„ 1 . A n a n tis e p tic is a c h e m ic a l t h a t c a n b e a d m in is t e r e d s a fe ly to
e x te r n a l b o d y s u r f a c e s o r m u c o u s m e m b r a n e s t o d e c r e a s e
m ic r o b ia l n u m b e r s . A n t is e p t ic s c a n n o t b e t a k e n in te r n a lly .
2 . A d is in fe c ta n t is a c h e m ic a l a g e n t u s e d to d e s t r o y
m ic r o o r g a n is m s o n in a n im a t e o b je c t s s u c h a s d is h e s , ta b le s , a n d
f lo o r s . D is in fe c ta n ts a r e n o t s a fe f o r liv in g tis s u e s .
in fe c tio n c o n tro l 298

T h e m o s t lik e ly ro u te fo r a d e n tis t to b e in fe c te d w ith H e p a titis C fro m

a p a tie n t is fro m th e in h a la tio n o f a e ro s o ls .
T h e r e is n o v a c c in a tio n fo r H e p a titis C .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• t h e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • th e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e
H e p a tit is C v ir u s ( H C V ) is t r a n s m it t e d p r im a r ily in in fe c te d b lo o d ( b lo o d
t r a n s f u s io n s ) . H is to r ic a lly , p a r e n te r a l d ru g a b u s e rs , p e rs o n s r e c e iv in g
t r a n s f u s io n s , o r g a n r e c ip ie n ts , a n d h e m o p h ilia c s r e c e iv in g f a c t o r V III o r IX
w e r e s h o w n to b e a t h ig h r is k o f H C V in fe c tio n . M o r e r e c e n tly , p e r s o n s
r e c e iv in g t a t t o o s o r u n d e r g o in g b o d y p ie r c in g s h a v e b e e n in fe c te d v ia
c o n t a m in a t e d , u n s t e r iliz e d n e e d le s .
„ 1. T h e m o s t lik e ly r o u te f o r a d e n tis t t o b e in fe c te d w it h H e p a titis C
fr o m a p a tie n t is fr o m a c o n t a m in a t e d n e e d le s t ic k ( a s o p p o s e d to
s a liv a o r t h e in h a la tio n o f a e r o s o ls ) .
2 . Im p o r ta n t: H e p a titis C is a s ig n if ic a n t r is k f a c t o r f o r t h e
d e v e lo p m e n t o f h e p a t o c e llu la r c a r c in o m a .
3 . T h e r e is n o v a c c in a tio n f o r H e p a titis C.
in fe c tio n c o n tro l 299

A 6 2 -y e a r -o ld m a le w a s p la c e d o n a v e n tila to r in th e IC U , p o s t e le c tiv e
s u r g e r y (C A B G ) d u e to m y o c a r d ia l in fa r c tio n . A fte r 4 8 h o u rs th e
p a tie n t d e v e lo p e d fe v e r , p u r u le n t s p u tu m , a n d r e s p ir a to r y d is tre s s
a n d w a s d ia g n o s e d w ith v e n tila to r -a s s o c ia te d p n e u m o n ia . P n e u m o n ia
a c q u ir e d in th e h o s p ita l is a n e x a m p le o f?

• c o m m u n it y a c q u ir e d in f e c t io n
• n o s o c o m ia l in fe c tio n
• o p p o r tu n is tic in fe c t io n
• s e c o n d a r y in fe c tio n

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • n o s o c o m ia l in fe c tio n
N o s o c o m ia l in fe c tio n s o r h o s p ita l a c q u ir e d in fe c tio n s ( H A I) o r ig in a t e in a
h o s p it a l, o r h o s p it a l- lik e s e tt in g , g e n e r a lly o c c u r r in g m o r e th a n 4 8 h o u r s a f t e r
h o s p ita l a d m is s io n . T h e y a r e a ls o k n o w n a s c o m p lic a t io n s a r is in g d u r in g
h o s p ita liz a tio n . P a t ie n t s in b u r n u n its a n d s u r g ic a l IC U s h a v e t h e h ig h e s t
r is k o f d e v e lo p in g n o s o c o m ia l in fe c tio n s .
S o u r c e s a n d m o d e s o f t r a n s m is s io n o f n o s o c o m ia l in fe c tio n s a r e a s
fo llo w s :
1. P a tie n t’s o w n m ic r o b io ta (r e s is ta n t o r g a n is m s a s s o c ia te d w ith
h o s p ita liz a tio n ), im m u n o c o m p r o m is e d d is e a s e or th e ra p y (d u e to
v u ln e r a b ilit y o f h o s p it a liz e d p a tie n ts ) .
2 . H o s p it a l p e r s o n n e l in c lu d in g h e a lt h c a r e p r o v id e r s , t h e r a p is t s , s tu d e n t s
w h o c o m e in c o n t a c t w it h t h e p a t ie n t a n d m a y t r a n s m it in fe c tio n .
3 . M e d ic a l e q u ip m e n t , i.e ., in d w e llin g u r in a r y c a th e te r s , in t r a v e n o u s lin e s ,
e n d o t r a c h e a l t u b e s t h a t c r o s s th e n o r m a l d e f e n s e b a r r ie r s g iv in g m ic r o b e s
a c c e s s to n o r m a lly s t e r ile flu id s a n d tis s u e s .
4 . C o m p le x d r u g -a lte r e d e n v ir o n m e n t o f t h e h o s p it a l s u c h a s h o s p ita l a ir ,
w a lls , f lo o r s , lin e n , w h ic h c a n b e s o u r c e s o f n o s o c o m ia l in f e c tio n .
5 . U n s a fe in je c tio n p r a c tic e s d u r in g w h ic h m e d ic a t io n s fr o m a s in g le
s y r in g e a r e a d m in is t e r e d to m u ltip le p a tie n ts .
C o m m u n ity -a c q u ir e d in fe c tio n s c a n o c c u r d u r in g h o s p ita liz a tio n b u t
d iffe r fr o m n o s o c o m ia l in fe c tio n s in t h a t c o m m u n it y - a c q u ir e d in fe c tio n s
a r e p r e s e n t o r a r e in c u b a tin g b e fo r e h o s p ita liz a tio n .
O p p o r tu n is tic in fe c tio n s a r e c a u s e d b y b a c te r ia , v ir u s e s , f u n g i, o r p r o to z o a
t h a t in fe c t p a t ie n t s w it h a c o m p r o m is e d im m u n e s y s te m . P a tie n ts w ith c y s tic
fib r o s is , u n c o n tr o lle d d ia b e te s m e llitu s , o r g a n tr a n s p la n ts , a n d a c q u ir e d
o r c o n g e n ita l im m u n e d e f ic ie n c ie s a r e a t h ig h r is k o f d e v e lo p in g
o p p o r t u n is t ic in fe c tio n s . N o r m a l r e s id e n t f lo r a p r o lif e r a t e s a n d c a u s e s d is e a s e
d u e to d e f e c t iv e d e fe n s e s y s te m s .
in fe c tio n c o n tro l 300

It is r e c o m m e n d e d th a t f a c e m a s k s b e c h a n g e d :

• b e tw e e n p a t ie n t s
• d a ily
• tw ic e p e r d a y
• tw ic e in th e m o r n in g a n d tw ic e in th e a ft e r n o o n

M IC R O B IO L O G Y /P A T H O L O G Y d M e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b e tw e e n p a tie n ts
F a c e m a s k s s h o u ld b e c h a n g e d a t le a s t w ith e v e r y p a tie n t a n d m o r e o ft e n if
h e a v y s p a t t e r is g e n e r a t e d d u r in g t r e a t m e n t . T h e C D C r e c o m m e n d s th a t
m a s k s b e c h a n g e d b e t w e e n p a t ie n t s o r d u r in g p a t ie n t t r e a t m e n t if th e m a s k
b e c o m e s w e t o r m o is t f r o m w ith in o r o u ts id e .
B F E ( B a c te r ia l F iltr a tio n E ffic ie n c y ) m e a s u r e s th e p e r c e n t e f fic ie n c y a t w h ic h
th e f a c e m a s k f ilt e r s b a c t e r ia p a s s in g t h r o u g h t h e m a s k .
P F E ( P a r tic u la te F iltr a tio n E f fic ie n c y ) m e a s u r e s th e p e r c e n t e f f ic ie n c y a t w h ic h
th e f a c e m a s k f ilt e r s p a r t ic u la t e m a t t e r p a s s in g t h r o u g h th e m a s k .
F lu id r e s is ta n c e is d e fin e d a s th e a b ility o f a f a c e m a s k 's m a te r ia l
c o n s t r u c t io n t o m in im iz e f lu id s f r o m tr a v e lin g t h r o u g h th e m a t e r ia l a n d
p o t e n t ia lly c o m in g in to c o n t a c t w it h th e u s e r o f th e fa c e m a s k . F lu id r e s is ta n c e
h e lp s r e d u c e p o te n tia l e x p o s u r e t o b lo o d a n d b o d y f lu id s c a u s e d fr o m
s p la s h e s , s p r a y , o r s p a tt e r .
in fe c tio n c o n tro l 301

L a te x a lle r g y ris k fa c to r s in c lu d e a ll o f th e fo llo w in g E X C E P T o n e .

W h ic h o n e is th e E X C E P T IO N ?

• p e r s o n s w ith m u lt ip le s u r g e r ie s
• a to p y
• r u b b e r in d u s tr y w o r k e r s
• p e r s o n s w ith a n a lle r g y to p o lle n
• p e r s o n s w ith a n a lle r g y to b a n a n a s

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • p e rs o n s w ith an a lle rg y to p o llen
P u b lis h e d s tu d ie s h a v e d e m o n s tr a te d a n in c r e a s e d r is k o f d e v e lo p in g a n a lle r g ic
re a c tio n to e ith e r la te x p ro te in (ty p e I) o r c e r ta in c h e m ic a ls u s e d in th e la te x
m a n u fa c tu r in g p r o c e s s (ty p e IV ) in c e r ta in g r o u p s o f p e o p le . C u r r e n t in fo r m a tio n has
n o t s h o w n a c r o s s -r e a c tio n b e tw e e n p o lle n a lle r g ie s a n d w a te r- s o lu b le la te x
a lle r g e n s . In d iv id u a ls w h o a p p e a r to b e p r e d is p o s e d to r e a d ily d e v e lo p in g ty p e I
h y p e r s e n s itiv ity r e a c tio n s (i.e ., w h o a re a to p ic ) , h o w e v e r , c a n b e c o m e s e n s itiz e d to
la te x a lle r g e n s m o re r e a d ily th a n p e o p le w ith fe w o r n o a lle r g ie s .
N o te: A to p y is th e g e n e tic te n d e n c y to d e v e lo p th e c la s s ic a lle r g ic d is e a s e s - a to p ic
d e r m a titis , a lle r g ic rh in itis ( h a y fe v e r ), a n d a s th m a . A to p y in v o lv e s th e c a p a c ity to
p r o d u c e Ig E in r e s p o n s e to c o m m o n e n v ir o n m e n ta l p r o te in s s u c h a s h o u s e
d u s tm ite s , g r a s s p o lle n , a n d fo o d a lle r g e n s .
R e m e m b er: N a iv e T c e lls fa ll in to tw o la rg e g r o u p s , o n e o f w h ic h c a r rie s th e c o ­
r e c e p to r C D 8 o n its s u r fa c e a n d th e o th e r b e a r s th e c o - r e c e p to r C D 4 . C D 8 T c ells a ll
d iffe r e n tia te in to C D 8 c y to to xic T c e lls (a k a , c y to to x ic ly m p h o c y te s o r C T L s ) , w h ic h
k ill th e ir ta r g e t c e lls . T h e y a re im p o r ta n t in th e d e fe n s e a g a in s t in tra c e llu la r
p a th o g e n s , e s p e c ia lly v iru se s . V ir u s - in fe c te d c e lls d is p la y fr a g m e n ts o f v ira l p r o te in s
a s p e p tid e - M H C c la s s I c o m p le x e s o n th e ir s u r fa c e a n d th e s e a r e r e c o g n iz e d b y
C D 8 c y to to x ic T c e lls .
C D 4 T c e lls , in c o n tr a s t, d iffe r e n tia te in to a n u m b e r o f d iffe r e n t e ffe c to r T c e lls w ith a
v a r ie ty o f fu n c tio n s . T h e m a in fu n c tio n a l s u b s e ts o f C D 4 e ffe c to r T c e lls n o w
r e c o g n iz e d a re T H1, T H2 , T H1 7 a n d th e re g u la to ry T c e lls . T h e s e s u b s e ts ,
p a r tic u la r ly T H1 , T H2, a n d T H17 a re d e fin e d o n th e b a s is o f th e d iffe r e n t c y to k in e s th a t
th e y s e c re te . T H1 c e lls p r o d u c e c y to k in e s th a t a c tiv a te m a c r o p h a g e s , e n a b lin g th e m
to d e s tr o y in tra c e llu la r m ic r o o r g a n is m s m o re e ffic ie n tly . T h e y c a n a ls o a c tiv a te
B c e lls to p r o d u c e s tr o n g ly o p s o n iz in g a n tib o d ie s b e lo n g in g to c e r ta in Ig G
s u b c la s s e s . T H2 c e lls , in c o n tra s t, p r o d u c e c y to k in e s th a t d r iv e B c e lls to d iffe r e n tia te
a n d p r o d u c e im m u n o g lo b u lin s o f o th e r ty p e s , e s p e c ia lly Ig E . T H1 7 c e lls in d u c e lo c a l
e p ith e lia l a n d s tr o m a l c e lls to p r o d u c e c h e m o k in e s th a t re c r u it n e u tr o p h ils to s ite s o f
in fe c tio n e a r ly in th e a d a p tiv e im m u n e re s p o n s e . R e g u la to ry T c ells s u p p r e s s T c e ll
a c tiv ity a n d h e lp p r e v e n t th e d e v e lo p m e n t o f a u to im m u n ity d u r in g th e im m u n e
re s p o n s e .
in fe c tio n c o n tr o l 302

W h ic h o f th e fo llo w in g p r e c a u tio n s th a t a r e p r a c tic e d in c o n ta g io u s

p a tie n ts fo r c o n tr o llin g th e s p r e a d o f in fe c tio n is N O T a c o m p o n e n t o f
is o la tio n m e a s u r e s ?

• u s e o f t r a n s m is s io n - b a s e d p r e c a u tio n s in a d d it io n to s ta n d a r d p r e c a u tio n s
• p la c e m e n t o f th e p a tie n t in a n e g a tiv e a ir flo w r o o m

• u s e o f v a c c in a tio n s
• u s e o f N 9 5 r e s p ir a to r m a s k s b y h o s p ita l p e r s o n n e l

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • use of v ac c in a tio n
Is o la tio n in v o lv e s th e p h y s ic a l s e p a r a tio n o f th o s e k n o w n o r s u s p e c te d to h a v e a
c o n ta g io u s d is e a s e in o r d e r to p re v e n t o r lim it th e s p r e a d o f d is e a s e .
Is o latio n p re c a u tio n s in c lu d e th e fo llo w in g :
1. S tan d a rd p rec a u tio n s
2. T ra n s m is s io n -b as e d p re c a u tio n s
S tan d a rd p re c a u tio n s a re a c o m b in a tio n o f u n ive rsa l p re c a u tio n s a n d b o d y
s u b s ta n c e iso latio n . S ta n d a r d p r e c a u tio n s a re u s e d to p r e v e n t h o s p ita l-b a s e d
in fe c tio n w h e r e th e r e a re h ig h c h a n c e s o f e x p o s u r e to in fe c te d b lo o d , o th e r b o d y
flu id s ( s e c r e tio n a n d e x c r e tio n , e x c e p t s w e a t) , n o n in ta c t s k in , a n d m u c o u s
m e m b ra n e s.
T ra n s m is s io n -b as e d p rec a u tio n sa re s e c o n d - tie r p r e c a u tio n s th a t a re used in
a d d itio n to s ta n d a r d p r e c a u tio n s
T ra n s m is s io n -b a s e d p re c a u tio n s in c lu d e th e fo llo w in g th re e c a teg o rie s :
1. C o n ta c t p rec a u tio n s a re in te n d e d to c h e c k th e tr a n s m is s io n o f in fe c tio u s a g e n ts
(lik e m e th ic illin - re s is ta n t Staphylococcus aureus, Clostridium difficile, e tc .) th a t
a re s p r e a d b y d ir e c t o r in d ire c t c o n ta c t w ith th e p a tie n t o r p a tie n t c a r e ite m s .
P a tie n ts p la c e d in c o n ta c t is o la tio n s h o u ld p r e fe r a b ly h a v e a p r iv a te ro o m .
C o n ta c t p r e c a u tio n s a ls o in c lu d e h a n d h y g ie n e , u s e o f g o w n , g lo v e s , m a s k s , a n d
e y e s h ie ld fo r p e r s o n n e l w h o c o m e in c o n ta c t w ith th e p a tie n t o r im m e d ia te
s u r r o u n d in g s .
2. D ro p le t p re c a u tio n s a re u s e d w h e n m o d e o f tr a n s m is s io n o f in fe c tio n is s p r e a d
b y d r o p le ts th a t a re g e n e r a te d w h e n a n in fe c te d p a tie n t c o u g h s , s n e e z e s , o r
s p o ts , s u c h a s w ith tu b e rc u lo s is in fe c tio n .
3. A irb o rn e p rec a u tio n s a re in te n d e d to c h e c k th e tr a n s m is s io n o f in fe c tio u s
a g e n ts w ith a s iz e le s s th a n 5 p m o r th o s e a tta c h e d to d u s t p a r tic le s , e .g .,
Varicella virus. P a tien ts a re p re fe ra b ly kept in a n e g ative a ir p re s s u re p rivate
ro o m an d h o sp ital p erso n n el s h o u ld w e a r N 95 re s p ira to r m asks (sp ecial
h ig h -d e n s ity m a s k s ) in th e is o la tio n ro o m . T h e p a tie n t s h o u ld w e a r an
a p p r o v e d r e s p ir a to r o u ts id e th e is o la tio n ro o m .
in fe c tio n c o n tr o l 303

E a c h o f th e fo llo w in g a re a d v a n ta g e s o f ra p id h e a t s te r iliz a tio n

E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• v e r y fa s t c y c le tim e
• n o d u llin g o f c u tt in g e d g e s
• d r y in s tr u m e n ts a f t e r c y c le
• d o e s n o t r e q u ir e p r e c le a n in g

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • d o e s n o t r e q u ir e p r e c le a n in g
F D A -a p p r o v e d , f o r c e d a ir , d r y h e a t c o n v e c tio n o v e n s a r e a p p r o p r ia t e fo r
s te r iliz a tio n o f h e a t - s t a b le in s tr u m e n ts a n d o t h e r r e u s a b le ite m s e m p lo y e d in
p a t ie n t c a r e . T h e y u s e a h ig h e r t e m p e r a t u r e t h a n o t h e r d r y h e a t u n it s , a n d
t h e r e is c o n tr o lle d in te r n a l a ir f lo w w ith in t h e c h a m b e r . In c o n t r a s t to th e
tr a d itio n a l ty p e o f d r y h e a t s te r iliz e r s , a r a p id h e a t tr a n s f e r u n it c a n a c h ie v e
s t e r iliz a t io n o f ite m s in s u b s t a n t ia lly s h o r t e r tim e s , w h ile s till o f f e r in g th e
a d v a n ta g e s o f d r y h e a t.
A d v a n c e s in th e d e s ig n o f t h e d r y h e a t o v e n h a v e r e s u lte d in t h e d e v e lo p m e n t
o f t h e d r y h e a t c o n v e c t io n u n it, w h ic h u s e s f o r c e d a ir a t h ig h e r te m p e r a t u r e s .
T h is m e th o d o f r a p id h e a t t r a n s f e r a c h ie v e s s t e r iliz a t io n in 1 2 m in u te s a t 3 7 5 °
F ( 1 9 0 ° C ) f o r w r a p p e d ite m s a n d in 6 m in u te s f o r u n w r a p p e d ite m s .
in fe c tio n c o n tro l 304

F o r e a c h n u m b e r e d d e fin it io n b e lo w , s e le c t th e m o s t c lo s e ly lin k e d
te rm fr o m th e lis t p ro v id e d .

1. G r o u p o f in d iv id u a ls a f fe c t e d b y A . B o d y s u b s ta n c e is o la t io n
c o m m o n d is e a s e C . R e v e r s e is o la tio n
2 . P r o te c t s m e d ic a l s ta ff a g a in s t D . Is o la t io n u n it
in f e c tio n b y p a tie n ts
E. P a tie n t c o h o r t
3. P a r t o f s ta n d a r d p r e c a u tio n s th a t
is o la t e s a ll b lo o d a n d b o d y f lu id s o f F . B a r r ie r n u r s in g
in fe c t e d p a tie n ts
4. P a t ie n t s s u ff e r in g fr o m
c o m m u n ic a b le d is e a s e a r e k e p t in
th is h o s p it a l u n it
5. Is o la tio n in im m u n o d e fic ie n t
p a tie n ts

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • 1 . E, 2 . F, 3 . A , 4 . D, 5 . C
is o la tio n u n it is a h o s p ita l u n it t h a t s e p a r a t e s p a tie n ts w ith c o m m u n ic a b le
d is e a s e s fr o m o t h e r p a tie n ts .
R e v e r s e is o la tio n , a ls o k n o w n a s p r o te c tiv e is o la tio n , in v o lv e s th e
s e p a r a tio n a n d c a r e o f im m u n o d e f ic ie n t p a tie n ts ( s u c h a s th o s e w h o h a v e
u n d e r g o n e c h e m o t h e r a p y o r o r g a n t r a n s p la n t s ) , s o t h a t t h e y c a n b e g u a r d e d
fr o m th e r is k o f c o n t a c t w it h p a t h o g e n ic m ic r o o r g a n is m s in t h e e n v ir o n m e n t.
B o d y s u b s ta n c e is o la tio n is a n in fe c tio n c o n tr o l m e th o d t h a t c o n s id e r s a ll
b o d y flu id s , i.e ., b lo o d , s e c r e tio n s , a n d e x c r e tio n s , a s p o t e n t ia lly in fe c t io u s ,
a n d t h a t s t ip u la t e s a n e ff e c tiv e ta s k - s p e c if ic b a r r ie r b e tw e e n t h e p a tie n t a n d
m e d ic a l p e r s o n n e l s h o u ld b e m a in ta in e d . B o d y s u b s ta n c e is o la tio n is an
im p o r ta n t c o m p o n e n t o f s ta n d a r d p r e c a u tio n s , i.e ., c o m b in a tio n of
u n iv e r s a l p r e c a u tio n s a n d b o d y s u b s ta n c e is o la tio n .
P a tie n t c o h o r t is a g r o u p o f p a tie n ts w it h t h e s a m e d is e a s e o r c o n d itio n w h o
a r e g r o u p e d to g e t h e r in a d e s ig n a t e d a r e a o f a u n it o r w a r d . T h e ir p r o g r e s s
c a n b e a s s e s s e d in a r e s e a r c h s tu d y . F o r e x a m p le , p a t ie n t c o h o r t is p r a c tic e d
in c o n ta c t is o la tio n w h e re th e in d iv id u a ls in fe c te d w it h th e sam e
m ic r o o r g a n is m m a y s h a r e t h e s a m e p r iv a te r o o m .
B a r r ie r n u r s in g is a ls o k n o w n a s b e d s id e is o la tio n . It is a fo r m o f in f e c tio n
c o n tr o l t h a t c h e c k s t h e t r a n s m is s io n o f in fe c tio n to m e d ic a l s ta ff fr o m p a tie n ts ,
p a r t ic u la r ly t h o s e w ith h ig h ly in fe c tio u s d is e a s e s , s u c h a s tu b e r c u lo s is . B a r r ie r
n u r s in g in v o lv e s th e u s e o f g lo v e s , g o w n s , a n d m a s k s to p r e v e n t t h e s p r e a d
o f in fe c t io n .
in fe c tio n c o n tro l 305

W h a t is th e m o s t im p o r ta n t p r e v e n tiv e m e a s u r e fo r th e s p re a d o f
n o s o c o m ia l in fe c tio n s in h o s p ita ls ?

• v a c c in e s
• s p r a y - w ip e - s p r a y
• h a n d w a s h in g
• is o la t io n m e a s u r e s

M IC R O B IO L O G Y /P A T H O L O G Y Ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 * © 2 0 1 7
 • h a n d w a sh in g
In a h e a lth c a re s e ttin g , h a n d w a s h in g is th e p r im a r y d is e a s e p r e v e n tio n m e a s u re
a g a in s t th e tr a n s m is s io n o f n o s o c o m ia l ( h o s p ita l-a c q u ire d ) p a th o g e n s .
M ic r o o r g a n is m s th a t d w e ll o n th e h a n d s c a n b e s u b d iv id e d in to fo llo w in g ty p e s :
1. R e s id e n t flo ra a re o r g a n is m s o f lo w v iru le n c e th a t a re n o t e a s ily re m o v e d b y h a n d ­
w a s h in g . T h e y a re ra re ly tra n s m itte d e x c e p t th r o u g h in v a s iv e p ro c e d u re s .
2. T ra n s ie n t flo ra a re th e m o s t im p o r ta n t c a u s e o f h o s p ita l-a s s o c ia te d in fe c tio n s th a t
a re a c q u ire d b y c o n ta c t o r a re lo o s e ly a tta c h e d to th e s k in . T h e y a re e a s ily
re m o v e d b y h a n d -w a s h in g .
T h u s , th e ro le o f h an d h y g ie n e in th e h o sp ital is to g et rid o f tra n s ie n t flo ra
a c q u ire d b y c o n ta ct w ith th e p atie n ts o r th e ir s u rro u n d in g e n v iro n m e n t.
H a n d h y g ie n e s h o u ld b e d o n e b e fo re :
• P e rfo rm in g in v a s iv e p r o c e d u re s
• H a n d lin g o p e n w o u n d s
• H a v in g d ire c t c o n ta c t w ith p a tie n ts in IC U s o r w ith n e w b o rn s
H a n d h y g ie n e s h o u ld a ls o b e p e r fo r m e d im m e d ia te ly a fte r to u c h in g th e s o u r c e th a t is
lik e ly to b e c o n ta m in a te d , c o n ta c t w ith p a tie n ts o r w ith o b je c ts in th e p a tie n t’s
im m e d ia te e n v iro n m e n t, a n d a ls o a fte r re m o v in g g lo v e s .
R o utin e han d h yg ie n e can be c arried o u t by th e fo llo w in g w ays :
• U s in g r e g u la r o r a n tim ic r o b ia l s o a p a n d w a te r w h e n h a n d s a re v is ib ly s o ile d o r
c o n ta m in a te d
• U s in g a lc o h o l-b a s e d h a n d ru b s w h e n h a n d s a re n o t v is ib ly s o ile d o r c o n ta m in a te d .
W a ll-m o u n te d d is p e n s e rs c o n ta in in g a lc o h o l-b a s e d h a n d ru b s s h o u ld b e p la c e d in all
h e a lth c a re fa c ilitie s . H e a lth c a re w o r k e r s s h o u ld c a r ry a s m a ll c o n ta in e r of h a n d ru b to
u s e w h e n d is p e n s e rs a re n o t a v a ila b le .
Is o latio n is a s p e c ia l p r e c a u tio n a r y m e a s u r e to c h e c k th e s p r e a d o f c o n ta g io u s
m ic r o o r g a n is m s a n d p r e v e n t e p id e m ic s . Is o la tio n s h o u ld be c a r rie d o u t w h e r e th e r e is
a h ig h ris k o f c r o s s - in fe c tio n , s u c h a s in IC U s . Is o la tio n m e a s u r e s re q u ire th a t all
in d iv id u a ls e n te rin g th e ro o m o f a n in fe c te d p a tie n t s h o u ld w e a r g lo v e s , g o w n , and
p o ss ib ly a m ask.
in fe c tio n c o n tr o l 306

W h ic h o n e o f th e fo llo w in g b a c te r ia is c a p a b le o f fo r m in g e n d o s p o r e s
a n d is th u s d iffic u lt to d e c o n ta m in a te w ith s ta n d a r d d is in fe c ta n ts o r
a u to c la v in g c o n d itio n s ?

• Lactobacillus
• Listeria
• Bacillus anthracis
• Corynebacterium

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • B a c illu s a n th ra c is
A n e n d o s p o r e is a t h ic k -w a lle d s t r u c tu r e f o r m e d b y s o m e b a c t e r ia . T h e th r e e
m o s t c o m m o n e x a m p le s o f b a c te r ia th a t fo r m e n d o s p o r e s a r e B a c illu s
a n th ra c is , C lo s trid iu m tetani, a n d C lo s trid iu m b o tu lin u m .
A b a c te r iu m f o r m s a n e n d o s p o r e w h e n t h e r e is a n u n f a v o r a b le c h a n g e in
e n v ir o n m e n t a l c o n d it io n s o r w h e n n u tr ie n ts a r e e x h a u s t e d ( s u c h a s d e p le tio n
o f c a r b o n , n itr o g e n , o r p h o s p h o r u s ) . E n d o s p o r e s a r e e s s e n t ia lly th e
d o r m a n t fo r m of th e b a c te r iu m , e n a b lin g it to s u r v iv e h a rs h
e n v ir o n m e n ta l c o n d itio n s ( in te n s e h e a t, r a d ia tio n , a n d d is in f e c t a n t s ) . In th e
e n d o s p o r e fo r m , b a c te r ia a r e d if f ic u lt t o d e c o n ta m in a te .
A n e n d o s p o r e d iff e r s in c o m p o s it io n fr o m t h e b a c t e r iu m ’s n o n - d o r m a n t s ta te .
T h e e n d o s p o r e c o n ta in s d ip ic o lin ic a c id a n d a h ig h c a lc iu m c o n t e n t , w h ic h
a llo w s it to b e h ig h ly r e s is ta n t t o h e a t a n d c h e m ic a ls . W h e n g r o w in g
c o n d it io n s im p r o v e , t h e e n d o s p o r e is a c t iv a t e d a n d th e b a c t e r iu m r e s u m e s its
v e g e t a t iv e life b y a c t iv e ly g r o w in g a n d r e p r o d u c in g . F o r e x a m p le , te ta n u s
c a u s e d b y Clostridium a n d a n t h r a x c a u s e d b y Bacillus a r e a s s o c ia te d w ith
e n d o s p o r e in fe c tio n o f w o u n d s , w h e r e u n d e r a p p r o p r ia t e c o n d itio n s , th e
e n d o s p o r e s a r e a c tiv a t e d .
G r a m - p o s it iv e r o d s o f m e d ic a l in te r e s t in c lu d e :

G ra m -p o s itiv e ro d s
E n d o s p o re fo rm in g Bacillus, Clostridium
R e g u la r, n o n -e n d o s p o re fo rm in g Lactobacillus, Listeria, Erysipelothrix
Irre g u la r, n o n -e n d o s p o re fo rm in g CorynebacteriumCorynebacterium
in fe c tio n c o n tro l 307

A th e r m o m e te r is a n e x a m p le o f w h ic h o f th e fo llo w in g S p a u ld in g
c la s s ific a tio n s ?

• c r itic a l
• s e m ic r itic a l
• s u b c r itic a l
• n o n c r itic a l

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 s e m ic r it ic a l

S p a u l d i n g ’s C la s s ific a tio n o f D c v ic c s/M e d ic a l In s tr u m e n ts

O b je c t a n d U s e o f ite m E x a m p le D e c o n ta m in a tio n re q u ir e d

C la s s if ic a tio n a f te r c le a n in g

C ritic a l E n ters v as cu la r s y s te m o r S ca lp e ls a n d o th e r su rgica l S te riliz a tio n a n d h o ld in g in

s te rile b o d y tissu es in s tru m e n ts su ch a s b io p s y ste riliz ed sta te . H ig h level
fo rce p s d is in fe ctio n is n o t su fficien t.

S e m i-C ritic a l C o m e s in c o n ta c t w ith in tact T h e rm o m e ter, vag inal S te riliz a tio n o r high -le v e l
m u c o u s m e m b ran e s s pe c u lu m , s ig m o id sc o p e d is in fe ctio n i f h e a t se n s itive

N o n -C ritic a l C o m e s in c o n ta c t w ith in ta c t E x a m in in g ta b le to p , b lo o d Inte rm e d ia te o r lo w level

sk in p res su re cu ff, b a b y w e ig h t scale d is in fe c tio n

R e m e m b e r : A ll in s t r u m e n t s to b e d is in f e c t e d o r s t e r iliz e d m u s t b e t h o r o u g h ly
c le a n e d t o r e m o v e a ll o r g a n ic m a t t e r ( b lo o d tis s u e ) a n d o t h e r r e s id u e . T h is
m u s t p r e c e d e d is in f e c t io n a n d s t e r iliz a t io n p r o c e d u r e s a s o r g a n ic m a t t e r
s h ie ld s o r g a n is m s fr o m d e s t r u c t io n a n d m a y in a c t iv a t e s o m e d is in f e c t a n t s .
in fe c tio n c o n tro l 308

E a c h o f th e fo llo w in g is c h a r a c te r is tic o f a lc o h o l-b a s e d h a n d h y g ie n e

a n tis e p tic s , E X C E P T o n e . W h ic h o n e is th e E X C E P T IO N ?

• b r o a d a n tim ic r o b ia l s p e c tr u m
• r e m o v a l o f o r g a n ic d e b r is fr o m c o n ta m in a te d h a n d s
• r a p id a n tib a c t e r ia l a c tio n
• g r e a te r a n tib a c te r ia l e f fe c t th a n a n io n ic d e te r g e n ts

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 13 * © 2 0 1 7
 • r e m o v a l o f o r g a n ic d e b r is fr o m c o n t a m in a t e d h a n d s
H a n d h y g ie n e a g e n ts w h ic h c o n ta in h ig h c o n c e n t r a t io n s o f a lc o h o l, d e n a t u r e
a n d d e h y d r a t e p r o te in s in s te a d o f a c c o m p lis h in g t h e r e m o v a l o f p r o te in a c e o u s
b io b u r d e n .
T h e u s e o f a lc o h o l- b a s e d h a n d a n t is e p t ic s ( h a n d s a n itiz e r s ) d o e s n o t r e p la c e
th e n e e d f o r fr e q u e n t a n d p r o p e r h a n d w a s h in g . T h e e ff ic a c y o f m o s t a lc o h o l-
b a s e d h a n d a n t is e p t ic s a p p r o x im a t e s s im p le h a n d w a s h in g . In a d d itio n , m a n y
a lc o h o l- b a s e d h a n d a n tis e p tic s h a v e v e r y p o o r a c tiv ity a g a in s t b a c te r ia l
s p o r e s , p r o to z o a n c y s ts a n d c e r ta in n o n - e n v e lo p e d v ir u s e s , such as
n o r o v ir u s e s . A lc o h o l- b a s e d h a n d a n t is e p t ic s a p p e a r t o h a v e v e r y g o o d to
e x c e lle n t a c tiv ity a g a in s t m a n y b a c t e r ia a n d s o m e e n v e lo p e d v ir u s e s . S o m e
s c ie n t if ic e v id e n c e s u g g e s t t h a t e t h a n o l- b a s e d h a n d a n t is e p t ic s c o n t a in in g 6 0 -
9 0 p e r c e n t a lc o h o l, a p p e a r t o b e t h e m o s t e ffe c t iv e a g a in s t c o m m o n
p a t h o g e n s ( in c lu d in g n o n - e n v e lo p e d v ir u s e s ) t h a t c a u s e a c u te g a s tr o e n te r itis .
In g e n e r a l, e th a n o l- b a s e d hand a n t is e p t ic s appear to have g re a te r
a n t im ic r o b ia l a c t iv it y a g a in s t v ir u s e s t h a n is o p r o p a n o l- b a s e d h a n d a n tis e p tic s ,
a lth o u g h b o th a p p e a r to o f f e r s o m e a c t iv it y a g a in s t t h e s e p a th o g e n s .
N o te : A lc o h o l- b a s e d h a n d a n t is e p t ic s a r e n o t e f f e c tiv e o n h a n d s t h a t a r e
v is ib ly d ir t y o r t h o s e c o n t a m in a t e d w it h o r g a n ic m a te r ia ls . H a n d s th a t a r e
v is ib ly d ir t y o r c o n t a m in a t e d w it h o r g a n ic m a te r ia l m u s t b e w a s h e d w it h s o a p
a n d w a te r , e v e n if h a n d a n t is e p t ic s a r e to b e u s e d a s a n a d ju n c t m e a s u r e . It is
a ls o w o r t h n o tin g t h a t t h e a m o u n t o f a lc o h o l- b a s e d h a n d a n t is e p t ic is
im p o r ta n t to its o v e r a ll e ff e c tiv e n e s s . F a ilu r e to c o v e r a ll s u r fa c e s o f t h e h a n d s
a n d fin g e r s w ill a ls o g r e a t ly r e d u c e th e e ff ic a c y o f a lc o h o l- b a s e d h a n d
a n tis e p tic s .
in fe c tio n c o n tr o l 309

W h ic h o f th e fo llo w in g ite m s is c o n s id e r e d r e g u la te d m e d ic a l w a s te
a n d c a n n o t b e d is p o s e d o f w ith g e n e r a l d e n ta l o ffic e tra s h ?

• g a u z e s o ile d w ith b lo o d , p la q u e , a n d s a liv a u s e d in a d e n ta l p r o p h y la x is

p ro c e d u re
• b lo o d - s a tu r a te d g a u z e u s e d in o r a l s u r g ic a l p r o c e d u r e s

• v is ib ly c o n ta m in a te d e n v ir o n m e n ta l s u r fa c e b a r r ie r s
• p la s tic s a liv a e je c to r s a n d h ig h - v o lu m e e v a c u a to r tip s

M IC R O B IO L O G Y /P A T H O L O G Y tfr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • b lo o d -s a tu ra te d g a u z e u se d in o ral s u rg ic al p ro c e d u re s
B lo o d -s a tu ra te d g a u z e is c o n s id e re d in fec tio u s, n o t m e re ly c o n ta m in a te d , a n d m e e ts
th e O S H A B lo o d b o rn e P a th o g e n s S ta n d a rd c rite ria fo r re g u la te d w a s te . It re q u ire s
s p e c ia l h a n d lin g a n d d is p o s a l.
R e g u lated M ed ical W a s te : T h is in c lu d e s in fe c tio u s a n d b io h a z a rd o u s w a s te d e fin e d
a s a s o lid o r liq u id th a t c o n ta in s p a th o g e n s in a d e q u a te n u m b e rs a n d w ith s u ffic ie n t
v iru le n c e to c a u s e in fe c tio u s d is e a s e in s u s c e p tib le h o s ts e x p o s e d to th e w a s te . T h is
w a s te c o u ld p o s e a th r e a t to h u m a n h e a lth o r th e e n v iro n m e n t. T h is ty p e o f w a s te
in c lu d e s :
• M ic ro b io lo g ic a l w a s te : c u ltu r e s a n d d is c a rd e d liv e a n d a tte n u a te d v iru s e s
• P a th o lo g ic a l w a s te : tis s u e ; e x tr a c te d te e th (w ith o u t a m a lg a m )
• B lo o d a n d b lo o d b y -p ro d u c ts
• A b s o r b e n t m a te ria ls c o n ta in in g la rg e v o lu m e s ( g r e a te r th a n 2 0 m L o f b lo o d a n d
b lo o d p ro d u c ts , s a liv a , n a s o p h a ry n g e a l s e c re tio n s , e tc .) w h ic h a re liq u id a n d a re
re la tiv e ly s lo w to d ry
• S h a rp s : h y p o d e rm ic n e e d le s , s y rin g e s and s c a lp e l b la d e s , e n d o d o n tic
file s /r e a m e r s , m a trix b a n d s , etc.
• A n e s th e tic c a r p u le s w ill b e c o n s id e r e d "s h a rp s " a n d in fe c tio u s w a s te d u e to th e ir
p o te n tia l to tra n s m it d is e a s e if th e y b e c o m e b ro k e n
G en eral w a s te : G e n e ra l w a s te w h ic h d o e s n o t p o s e a s ig n ific a n t ris k o f c a u s in g o r
tr a n s m ittin g c o m m u n ic a b le d is e a s e o r in fe c tio n u n d e r o r d in a r y c irc u m s ta n c e s . T h is
ty p e of w a s te in c lu d e s :
• A b s o r b e n t m a te ria ls c o n ta in in g b lo o d , s a liv a , n a s o p h a r y n g e a l s e c re tio n s , e tc . a n d
w h ic h a re n o n -liq u id a n d d ry r e la tiv e ly fa s t
• In fe c tio u s w a s te w h ic h h a s b e e n s te r iliz e d
• A ll s o lid o r liq u id w a s te g e n e ra te d d u rin g p a tie n t c a re n o t c la s s ifie d a s in fe c tio u s
• S h a ll in c lu d e , b u t n o t lim ite d to , w a s te s u c h a s e m p ty s p e c im e n c o n ta in e rs ,
b a n d a g e s , d r e s s in g s a n d a b s o r b e n t m a te ria ls c o n ta in in g n o n - liq u id b lo o d , s u rg ic a l
g lo v e s , d e c o n ta m in a te d b io h a z a rd o u s w a s te , a n d o th e r m a te ria ls w h ic h a re n o t
b io h a z a rd o u s
• A ll w a s te m u s t b e d is p o s e d o f a c c o r d in g to a p p lic a b le fe d e r a l, s ta te a n d lo c a l
re c o m m e n d a tio n s
in fe c tio n c o n tro l 310

Ia tr o g e n ic in fe c tio n s in th e d e n ta l s e ttin g m a y b e in d u c e d :

• b y f a ilu r e to p e r fo r m h a n d h y g ie n e b e tw e e n p a tie n t p r o c e d u r e s
• b y p e r fo r m in g tr e a t m e n t p r o c e d u r e s
• in p a tie n ts w ith d e b ilita te d o r c o m p r o m is e d im m u n e d e fe n s e s
• a ll o f th e a b o v e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • a ll o f t h e a b o v e
Ia tr o g e n ic in fe c tio n s c a n b e in it ia te d b y a n y a c t iv it y r e la te d to th e p r o v is io n o f
h e a lth c a r e , in c lu d in g m e d ic a l o r d e n t a l t r e a t m e n t s a n d d ia g n o s t ic p r o c e d u r e s ,
r e g a r d le s s o f w h e t h e r th e y a r e p e r fo r m e d p r o p e r ly a n d r e g a r d le s s o f h o s t
im m u n it y . T h e s e in fe c tio n s a r e a ls o c a lle d o p p o r t u n is t ic if t h e y c o u ld n o t
n o r m a lly d e v e lo p in p e r s o n s w it h o u t c o m p r o m is e d h o s t im m u n it y .
in fe c tio n c o n tro l 311

G lo v e s , g o w n s , m a s k s , g o g g le s , a n d a p r o n s a r e p e rs o n a l p r o te c tiv e
e q u ip m e n t.
S u r g ic a l g lo v e s p r o v id e f ir s t-lin e d e fe n s e a g a in s t m ic ro b ia l
c o n ta m in a tio n .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e f ir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• th e f ir s t s ta te m e n t is fa ls e , t h e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a rt I • V o lu m e 1 3 • © 2 0 1 7
 • the firs t statem en t is true, the seco n d is false
In a h e a l t h c a r e s e t t in g , personal p ro tective eq u ip m e nt (P P E ) a r e w o r n b y p a t i e n t c a r e p r o v i d e r s a s
p ro tective barriers. P P E in c l u d e i t e m s s u c h a s g lo v e s , g o w n s , f a c e m a s k s , p r o t e c t i v e e y e w e a r ,
a p ro n s , and o th e r e q u ip m e n t. These p r o te c tiv e b a r r ie r s p ro te c t a g a in s t tra n s m is s ib le d is e a s e s or
h a r m f u l c h e m ic a ls .

P e r s o n a l p r o t e c t i v e e q u i p m e n t is d e t a i l e d a s f o llo w s :

G loves

G l o v e s s h o u l d b e w o r n b e f o r e t o u c h i n g a n y b o d y f lu id , b lo o d , s e c r e t i o n s , e x c r e t i o n s , c o n t a m i n a t e d
i te m s , a n d b e f o r e t o u c h in g m u c o u s m e m b r a n e s a n d n o n i n t a c t s k in .

S urgical glove s are c on side re d a second line of d efen se ( h a n d h y g ie n e b e in g t h e f i r s t lin e o f

d e f e n s e ) a g a i n s t m ic r o b i a l c o n t a m i n a t i o n .

G l o v e s s h o u l d b e c h a n g e d b e t w e e n t a s k s a n d p r o c e d u r e s o n t h e s a m e p a t i e n t o r a f t e r c o n t a c t w it h
m a t e r i a l t h a t h a s h ig h r i s k o f b e in g c o n t a m i n a t e d w it h m ic r o o r g a n i s m s .

G l o v e s s h o u l d b e r e m o v e d a f t e r u s e , b e f o r e t o u c h i n g n o n c o n t a m i n a t e d o b je c t s a n d s u r f a c e s , a n d
b e f o r e c a r in g f o r a n o t h e r p a t ie n t .

th ic k er glove s or d o u b le-gloving is p r e f e r r e d .
In o r d e r t o p r e v e n t t h e b r e a c h o f g l o v e b y p e r f o r a t i o n ,
D o u b l e - g lo v i n g w ith a d a r k - c o l o r e d ind icator u nd er the glove s h e lp s in id e n t i f y i n g a p e r f o r a t io n .
H a n d s s h o u l d b e w a s h e d p r io r t o a n d im m e d i a t e l y a f t e r t h e u s e o f g lo v e s t o p r e v e n t t r a n s m i s s i o n o f
m ic r o o r g a n i s m s .

Gown

A g o w n s h o u l d b e w o r n a s a b a r r i e r f o r p r o t e c t i n g t h e s k in a n d c lo t h in g o f m e d i c a l p e r s o n n e l d u r in g
p a tie n t c a r e p r o c e d u r e s a n d a c t iv itie s .

G ow ns should h ave long sleeves w ith ela stic cu ffs m ade of im p erm eable or w ater resistant
material.
S o i l e d g o w n s s h o u l d b e r e m o v e d im m e d i a t e l y a f t e r a t t e n d i n g t o a p a t ie n t a n d h a n d w a s h i n g is h i g h l y
r e c o m m e n d e d in o r d e r t o m a in t a i n a s e p s is .

M ask, eye p rotection, fa c e shield

A m a s k , e y e p r o t e c t i o n ( g o g g l e s ) , a n d a f a c e s h i e l d h e lp p r o t e c t t h e m u c o u s m e m b r a n e s o f t h e e y e s ,
n o s e , a n d m o u t h d u r i n g la b p r o c e d u r e s o r p a t i e n t c a r e a c t i v i t i e s .
in fe c tio n c o n tro l 312

U s in g a u to m a te d c le a n in g e q u ip m e n t is m o re tim e e ffic ie n t, im p ro v e s
c le a n in g e ffe c tiv e n e s s , a n d is s a fe r th a n h a n d -s c r u b b in g .
C le a n e d in s tr u m e n ts n e e d n o t b e w r a p p e d n o r h e a t s te r iliz e d p rio r to
u s e o n s u b s e q u e n t p a tie n ts .

• b o t h s t a te m e n ts a r e tr u e
• b o th s ta te m e n ts a r e fa ls e
• th e fir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
• t h e fir s t s ta te m e n t is fa ls e , th e s e c o n d is tr u e

M IC R O B IO L O G Y /P A T H O L O G Y ifr d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • th e fir s t s ta te m e n t is tr u e , th e s e c o n d is fa ls e
W h e n a u t o m a t e d c le a n in g e q u ip m e n t, s u c h a s a n u lt r a s o n ic u n it o r a w a s h e r -
d is in fe c to r , is r o u tin e ly u s e d in in s t r u m e n t r e p r o c e s s in g , c le a n in g e ff e c t iv e n e s s
im p r o v e s a n d th e p o te n tia l r is k s fr o m a c c id e n t a l s h a r p s e x p o s u r e s w ith
c o n t a m in a t e d in s t r u m e n t s d e c r e a s e s . C le a n e d in s t r u m e n t s m u s t s till b e
w r a p p e d a n d h e a t s t e r iliz e d p r io r to u s e o n s u b s e q u e n t p a tie n ts . H e a t
s t e r iliz a t io n r e m a in s t h e “ g o ld s t a n d a r d ” f o r d e s t r u c t io n o f m ic r o b ia l p a th o g e n s .
N o te : D is p o s a b le , o r s in g le - u s e ite m s , a r e n o t in te n d e d to b e c le a n e d a n d
s te r iliz e d f o r r e u s e o n a n o t h e r p a tie n t, b e c a u s e th e y a r e u s u a lly n o t h e a t-
t o le r a n t a n d c a n n o t b e r e a d ily c le a n e d .
in fe c tio n c o n tro l 313

A c c o r d in g to th e O c c u p a tio n a l S a fe ty a n d H e a lth A d m in is tr a tio n

(O S H A ) B lo o d b o r n e P a th o g e n s S ta n d a rd , d is p o s a b le g lo v e s th a t h a v e
b e e n c o n ta m in a te d s h a ll b e re p la c e d :

• im m e d ia te ly
• a s s o o n a s p o s s ib le

• a s s o o n a s fe a s ib le
• a s s o o n a s p r a c tic a l

M IC R O B IO L O G Y /P A T H O L O G Y i* d e n ta ld e c k s
P a r t I • V o lu m e 1 3 * © 2 0 1 7
 • a s s o o n a s p r a c tic a l
C o n t a m in a t io n o f th e o u t s id e s u r f a c e o f g lo v e s d u r in g p a t ie n t c a r e d o e s n o t
r e q u ir e u r g e n t a c tio n . T h e O S H A B lo o d b o r n e P a t h o g e n s S t a n d a r d s ta te s :
“ D is p o s a b le ( s in g le u s e ) g lo v e s s u c h a s s u r g ic a l o r e x a m in a t io n g lo v e s , s h a ll
b e r e p la c e d a s s o o n a s p r a c tic a l w h e n c o n t a m in a t e d o r a s s o o n a s f e a s ib le
if t h e y a r e to r n , p u n c tu r e d , o r w h e n t h e ir a b ilit y to f u n c t io n a s a b a r r ie r is
c o m p r o m is e d . ”
in fe c tio n c o n tro l 314

S ta n d a r d p r e c a u tio n s s h o u ld b e p ra c tic e d w h e n th e r e is ris k o f

tr a n s m is s io n o f in fe c tio u s p a th o g e n s . W h ic h o f th e fo llo w in g
s p e c im e n s is e x e m p te d fr o m s ta n d a r d p r e c a u tio n s ?

• u r in e
• m u c o u s m e m b r a n e s a n d n o n - in t a c t s k in
• p e r s p ir a tio n
• b lo o d

M IC R O B IO L O G Y /P A T H O L O G Y l^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • p ersp iratio n
S tan d ard p re c a u tio n s a re a s e t o f s tr a te g ie s d e s ig n e d to d e c r e a s e th e ris k of
s p r e a d o f in fe c tio u s p a th o g e n s fr o m b o th id e n tifie d a n d u n id e n tifie d s o u r c e s . T h e s e
p re c a u tio n s a re a p p lic a b le to b lo o d , a ll b o d y flu id s , s e c r e tio n s , e x c r e tio n s (except
s w e a t r e g a r d le s s o f w h e th e r o r n o t v is ib le b lo o d is p r e s e n t) , n o n - in ta c t s k in (c u ts ,
a b r a s io n s , d e r m a titis , e tc .), a n d m u c o u s m e m b r a n e s ( m o u th , n o s e , e y e ), w h ic h a re
r e c o g n iz e d a s th e p r im a r y s o u r c e s o f tr a n s m is s io n o f in fe c tio n .
S ta n d a r d p r e c a u tio n s c a m e in to e x is te n c e in 1996 b y e n c o m p a s s in g b o th u n ive rsa l
p re c a u tio n s a n d b o d y s u b s ta n c e iso lation p re c a u tio n s. U n iv e r s a l p r e c a u tio n s ,
d e v is e d b y C e n te r s fo r D is e a s e C o n tr o l a n d P r e v e n tio n ( C D C ) in 1 9 8 7 , w e r e a s e t o f
in fe c tio n c o n tro l p r a c tic e s a n d p r o c e d u r e s b a s e d o n th e c o n c e p t th a t a ll b lo o d a n d
o th e r b o d y flu id s th a t m ig h t b e c o n ta m in a te d w ith b lo o d s h o u ld b e tr e a te d a s
in fe c tio u s . B o d y s u b s ta n c e is o la tio n p re c a u tio n s w e r e d e v e lo p e d in 1 9 8 4 w ith th e a im
o f p ro te c tin g h e a lth c a re w o r k e r s fro m m ic r o b ia l tr a n s m is s io n fr o m m o is t b o d y
s u r fa c e s . T h u s , s ta n d a r d p re c a u tio n s s u p e r s e d e d a n d c o m b in e d th e p r e v io u s
g u id e lin e s o f b o th u n iv e r s a l p r e c a u tio n s a n d b o d y s u b s ta n c e is o la tio n . It is d iffic u lt to
d e te r m in e b e fo r e h a n d w h e th e r a p a r tic u la r p a tie n t is in fe c tio u s o r n o t, th e r e fo r e ,
s ta n d ard p rec a u tio n s sh o u ld be ro u tin ely p ra c tic e d fo r all p atien ts.
T h e v a r io u s c o m p o n en ts of s tan d a rd p re c a u tio n s in c lu d e h an d h yg ie n e a n d
a p p r o p r ia te b a r r ie r s b y w e a rin g p e r s o n a l p r o te c tiv e e q u ip m e n t s u c h a s g lo ve s , fa c e
m ask, p ro te c tiv e e ye w e a r (g o g g les ), an d g o w n . A p p r o p r ia te m e a s u r e s s h o u ld b e
ta k e n to m a n a g e s o ile d p a tie n t c a re e q u ip m e n t, c o n tr o l th e h o s p ita l e n v ir o n m e n t
th r o u g h c le a n in g a n d d is in fe c tio n , a n d p r o p e r ly h a n d le p a tie n t’s lin e n to p re v e n t
tr a n s m is s io n o f in fe c tio n . S a fe in je c tio n p r a c tic e s s h o u ld b e fo llo w e d s u c h a s u s e o f
s te r ile s in g le - u s e d is p o s a b le n e e d le s a n d m a n a g e m e n t o f u s e d s h a r p s .
R e s u s c ita tio n b a g , m o u th p ie c e a n d o th e r d e v ic e s s h o u ld b e u s e d to a v o id c o n ta c t
w ith th e p a tie n t’s m o u th a n d o ra l s e c r e tio n s . A s in g le - o c c u p a n c y ro o m is
r e c o m m e n d e d if th e p a tie n t is a t a n in c re a s e d r is k o f tr a n s m is s io n o f in fe c tio n . C o u g h
e tiq u e tte s h o u ld b e ta u g h t a n d fo llo w e d .
in fe c tio n c o n tro l 315

U s in g c a s s e tte s to p r o c e s s a n d r e -c ir c u la te in s tr u m e n ts in c lin ic a l
s e ttin g s c a n :

• m a k e in s tr u m e n t p r o c e s s in g m o r e e ff ic ie n t
• in c r e a s e o r g a n iz a tio n o f d e n t a l in s tr u m e n ts
• d e c r e a s e h a n d lin g o f c o n ta m in a te d in s tr u m e n ts d u r in g c le a n in g
p ro c e d u re s
• r e d u c e th e p o te n t ia l f o r a c c id e n ta l s h a r p s in ju r ie s
• a ll o f th e a b o v e

M IC R O B IO L O G Y /P A T H O L O G Y i^ d e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 • a ll o f t h e a b o v e
C a s s e t t e s p r o v id e a n a lt e r n a t iv e a p p r o a c h f o r r e p r o c e s s in g in s t r u m e n t s t h a t
a d d re s s e s a num ber o f o c c u p a t io n a l is s u e s e n c o u n te re d by h e a lth
p r o f e s s io n a ls w h e n h a n d lin g s h a r p , c o n t a m in a t e d in s tr u m e n ts .
U s in g c a s s e t t e s f o r r e p r o c e s s in g in s tr u m e n ts :
• R e q u ir e s le s s h a n d lin g o f c o n t a m in a t e d in s t r u m e n t s
• D e c r e a s e s t h e r is k o f s h a r p s in ju r ie s d u r in g r e p r o c e s s in g
• G iv e s th e c a p a c it y t o h o ld a c o m p le t e s e t o f in s t r u m e n t s fo r a s in g le
p ro c e d u re
• C a n s a v e t im e b y k e e p in g a ll in s t r u m e n t s f o r a s p e c if ic p r o c e d u r e to g e t h e r
th r o u g h th e r e p r o c e s s in g c y c le
in fe c tio n c o n tr o l 316

W h ic h o f t h e fo llo w in g h o s p ita l w a s te is d e s ig n a te d b y C e n te r s fo r
D is e a s e C o n tro l a n d P re v e n tio n (C D C ) a s r e g u la te d m e d ic a l w a s te ?

• m ic r o b io lo g y la b o r a to r y w a s t e
• b lo o d

• s h a rp s
• p a th o lo g y a n d a n a to m y w a s te

• c o n ta m in a te d a n im a l c a r c a s s e s
• a ll o f th e a b o v e

M IC R O B IO L O G Y /P A T H O L O G Y IM e n ta ld e c k s
P a r t I • V o lu m e 1 3 • © 2 0 1 7
 all of the above
Regulated medical waste ( p r e v i o u s l y c a lle d infectious waste) is d e fi n e d a s a m e d ic a l w a s te t h a t is c a p a b le
o f p r o d u c in g a n in fe c tio u s d is e a s e . It c o n ta in s v ir u le n t p a th o g e n s in e n o u g h q u a n tit y , a n d w h e n a s u s c e p tib le
h u m a n h o s t is e x p o s e d to s u c h w a s te , it r e s u lts in a n in f e c tio u s d is e a s e . Hospital waste, such as
microbiology laboratory waste, pathology and anatomy waste, contaminated animal carcasses, blood,
and sharps, is d e s ig n a te d a s r e g u la t e d m e d ic a l w a s te b y th e C e n te r s fo r D is e a s e C o n tr o l a n d P r e v e n tio n
(C D C ).

T h e U S E n v ir o n m e n t a l P r o te c tio n A g e n c y (EPA) a ls o c o n s id e r s th e five C D C - d e s ig n a te d w a s te s a s r e g u la te d

m e d ic a l w a s te . M o r e o v e r , th e E P A a ls o in c lu d e d communicable disease isolation waste a s r e g u la te d
m e d ic a l w a s te .

Note: In th e Medical Waste Tracking Act ( M W T A ) , th e E P A in c lu d e d o n ly “ h ig h ly ” c o m m u n ic a b le d is e a s e

w a s te s u c h a s th o s e c a u s e d b y C la s s 4 in fe c tio u s a g e n ts ( e .g ., M a r b u r g , E b o la , a n d Lassa v ir u s e s ) a s
r e g u la t e d m e d ic a l w a s te .

Type of regulated Description

medical waste
• S to c k s a n d c u ltu r e s o f in fe c t io u s a g e n t s
1. Microbiologic • W a s te s fr o m th e p r o d u c tio n o f b io lo g ic a ls , t h r o w n - a w a y liv e a n d a tt e n u a te d
laboratory waste v a c c in e s
• C u ltu r e d is h e s a n d a p p a r a tu s u s e d to tr a n s fe r , in o c u la te , a n d m ix c u lt u r e s

T is s u e s , o r g a n s , a n d b o d y p a r ts th a t a r e r e m o v e d d u r in g s u r g ic a l p r o c e d u r e s o r
2. Pathologic waste
a u to p s ie s

3. Blood and blood

W a s te h u m a n b lo o d a n d b lo o d p r o d u c ts s u c h a s s e r u m a n d p la s m a
products

H y p o d e r m ic n e e d le s , s y r in g e s , P a s te u r p ip e tte s , b r o k e n g la s s , a n d s c a lp e l
4. Sharps b la d e s

5. Contaminated animal A n im a l c a r c a s s e s , b o d y p a r ts , a n d b e d d in g o f a n im a ls c o n ta m in a te d d u r in g
carcasses r e s e a r c h , p r o d u c tio n o f b io lo g ic a ls , o r p h a r m a c e u ti c a ls te s tin g

In th e p a s t, regulated medical waste w a s d is p o s e d o f p r im a r ily b y incineration. E m is s io n r e g u la t io n s h a v e

lim ite d th e u s e o f in c in e r a tio n b y h o s p ita ls . T h u s , a u to c l a v e s a n d s te a m s te r iliz e r s h a v e b e c o m e th e p r im a r y
te c h n o lo g y fo r r e g u la te d m e d ic a l w a s te d is p o s a l. O th e r n o n in c in e r a tio n d is p o s a l m e th o d s s u c h a s
m e c h a n ic a l/c h e m ic a l d is in f e c tio n , m ic r o w a v e d e c o n ta m in a t io n , s te a m d is in fe c tio n , a n d c o m p a c tin g h a v e a ls o
b e e n p r o p o s e d . N o n r e g u la te d m e d ic a l w a s te is d is p o s e d in p r o p e r ly r e g u la t e d s a n it a r y la n d fills (a s a fe a n d
in e x p e n s iv e d is p o s a l m e th o d ) .