Questions Explanation

1
A 24-year-old man comes to the emergency department due to severe nausea and vomiting 2
hours after a church picnic. He ate chicken salad that had been sitting out in the sun. The
patient has no prior medical conditions. Temperature is 37.2 C (98.9 F), blood pressure is
126/84 mm Hg, and pulse is 86/min. No abdominal tenderness is present, and bowel sounds
are normal. Blood cell counts and serum chemistry studies are within normal limits. Symptoms
improve significantly within several hours with supportive care. Which of the following is the
most likely cause of this patient's symptoms?
Bacterial exotoxin production in the gut [9%]

A.
Bacterial invasion of the gut mucosa [2%]

B.
Ingestion of preformed enterotoxin [85%]
C.
Microbial attachment to the intestinal surface [1%]

D.
Systemic absorption of luminal endotoxin [1%]

E.
Enterotoxigenic Staphylococcus aureus is a leading cause of foodborne illness. This pathogen
Microbiology 1 Page 1
Enterotoxigenic Staphylococcus aureus is a leading cause of foodborne illness. This pathogen
inoculates food during unsanitary preparation by an asymptomatic carrier. Storage of the food
at room temperature for extended periods (eg, picnic, pot luck meal) allows the bacteria to
proliferate and generate a heat-stable enterotoxin. Ingestion of the preformed toxin leads
to rapid-onset illness that includes nausea, vomiting, and abdominal pain. Occasionally, mild
fever and diarrhea may also be present. Symptoms resolve in a few hours with symptomatic
care.
Because the disease is due to the ingestion of a preformed toxin, no person-to-person
transmission occurs. However, outbreaks may arise when people eat the same contaminated
food at an event or party. High risk foods include dairy products, produce, precooked meat,
eggs, and mayonnaise-based salads(eg, chicken salad).
A similar clinical picture of rapid-onset nausea, vomiting, and abdominal cramping can be seen
with food-borne illness due to Bacillus cereus, which also produces a heat-stable enterotoxin. B
cereuscharacteristically contaminates starchy foods (eg, rice); illness is often associated with
reheated rice.
(Choices A, B, and D) Foodborne illness can also be caused by other bacterial mechanisms,
such as:
• Enterotoxin production within the intestine by enterotoxigenic Escherichia coli (ETEC)
and Vibrio cholera, whose toxins cause watery diarrhea, and enterohemorrhagic E
coli (EHEC) and Shigella, whose toxins cause inflammatory/bloody diarrhea
• Bacterial invasion of the intestinal mucosa by Salmonella, enteroinvasive E coli (EIEC),
and Campylobacter jejuni causes inflammatory/bloody diarrhea
• Enteropathogenic E coli (EPEC) attaches to enterocytes and effaces their surface, resulting
in watery diarrhea; this strain does not produce toxins
However, gastroenteritis due to these bacteria generally takes >24 hours to manifest, as the
bacteria require time to proliferate and subsequently produce enterotoxin and/or invade the
intestinal epithelium.
(Choice E) Most gram-negative enteric pathogens contain endotoxin (lipopolysaccharide) that
is released upon cell lysis. However, endotoxin released in the gastrointestinal tract is not
typically absorbed in sufficient quantities to cause systemic illness. Endotoxin-mediated illness
(eg, sepsis) occurs when gram-negative bacteria are present in the bloodstream.
Educational objective:
Staphylococcal food poisoning is mediated by the ingestion of a preformed, heat-stable
enterotoxin that induces rapid-onset (<6 hours) nausea and vomiting. Most cases arise due to
improper food handling and storage. Common culprit foods include eggs, dairy products, and
mayonnaise-based salads.
2
A 59-year-old female is brought to the ER with fever, skin flushing, and an altered level of
consciousness. Her blood pressure is 50/20 mmHg, and her heart rate is 120/min. If blood
cultures are positive for E. coli, which of the following bacterial factors is most likely responsible
for this patient's current condition?
Capsule [10%]
A.
Heat-stable exotoxin [16%]

B.
O antigen [10%]
C.
Fimbrial antigen [8%]

D.
Lipid A [52%]
E.
Flagellar antigen [1%]

F.
This woman is suffering from septic shock. Septic shock results from the release of endotoxins
into the bloodstream. Regardless of the bacterial source, most mammals, including humans,
experience the same range of toxic, biological effects as a result of these endotoxins.
Endotoxins are found in the outer membrane of Gram-negative bacteria, which is composed of
lipopolysaccharide (LPS). LPS is released during destruction of the bacterial cell wall. It can also
be released during cell division. LPS is a very long, heat-stable molecule arranged into three
regions: O antigen, core polysaccharide, and Lipid A. Lipid A is responsible for the toxic
properties of LPS that lead to Gram-negative sepsis and endotoxic septic shock.
Lipid A induces shock by activation of macrophages and granulocytes. This activation results in
the synthesis of endogenous pyrogens, such as IL-1, prostaglandins, and the inflammatory
mediators: tumor necrosis factor-alpha (TNF-alpha) and interferon. These cytokines then
induce a febrile response by the action of IL-1 on the hypothalamus, as well as hypotension,
increased vascular permeability with third-spacing of fluids, diarrhea, disseminated
intravascular coagulation, and death.
(Choice A) E. coli strains that cause neonatal meningitis synthesize K-1 capsular antigens.
(Choice B) Heat-stable exotoxin is one of the enterotoxins produced by ETEC.
(Choice C) The O antigen is a cell wall outer membrane polysaccharide antigen used to classify
gram-negative bacteria.
gram-negative bacteria.
(Choice D) Fimbriae, or pili, are a virulence factor that allow bacteria to adhere to the target
tissue and establish infection. Examples of organisms that use pili are Neisseria meningitidis,
uropathogenic and diarrheogenic E. coli, Bordetella pertussis, and Vibrio cholerae.
(Choice F) Flagellar (H) antigen is a heat-labile protein which is one component of the serologic
classification of the enterobacteriaceae.
Educational Objective:
Gram-negative sepsis is caused by the release of LPS from bacterial cells during division or by
bacteriolysis; LPS is not actively secreted by bacteria. Lipid A is the toxic component of LPS; it
causes activation of macrophages leading to the widespread release of IL-1 and TNF-alpha,
which cause the signs and symptoms of septic shock: fever, hypotension, diarrhea, oliguria,
vascular compromise, and DIC.
3
A 26-year-old man is brought to the emergency department due to fever and lethargy. His
girlfriend says the patient abruptly began experiencing fever, chills, vomiting, and diarrhea
several hours ago, which were quickly followed by lightheadedness and lethargy. He has no
prior medical conditions other than an episode of epistaxis after a bar fight 3 days ago. The
patient does not smoke cigarettes or use injection drugs. There is no history of exposure to sick
contacts, and he has not eaten anything out of the ordinary. Temperature is 38.9 C (102 F),
blood pressure is 90/60 mm Hg, and pulse is 120/min. Physical examination shows a diffuse,
erythematous rash. There is an anterior nasal packing in the left nostril, removal of which
shows mild mucosal erythema with a purulent discharge. Cardiopulmonary and abdominal
examinations reveal no abnormalities, and signs of meningeal irritation are absent. Which of
the following processes is most essential in pathogenesis of this patient's current condition?
Activation of toll-like receptors by bacterial components [24%]

A.
Binding of T-cell receptors by bacterial secretory products [55%]
B.
Bridging of cell-bound IgE by multivalent antigens [3%]

C.
Phagocytosis of bacteria in the blood by neutrophils [8%]

D.
Presentation of processed antigens by dendritic cells [6%]

E.
Staphylococcal toxic shock syndrome (TSS) is an exotoxin-mediated disease associated with
rapid-onset high fever, hypotension, multiorgan failure, and a diffuse, erythematous
rash. Most cases are linked to prolonged tampon use or nasal wound packing, which provides
a medium for localized Staphylococcus aureus proliferation and the elaboration of pyrogenic
toxin superantigens (eg, toxic shock syndrome toxin-1 [TSST-1]) into the bloodstream.
Pyrogenic toxin superantigens are generated by strains of S aureus (and Streptococcus
pyogenes) that have acquired an underlying mobile genetic element via bacteriophage or
plasmid. These exotoxins are called superantigens because they bind to the invariant region of
the MHC-II complex of antigen-presenting cells without first being internalized and processed
(MHC-II antigens are normally processed by the phagolysosome) (Choice E). The
superantigen/MHC-II complex subsequently interacts with the variable part of the T-cell
receptor beta chain, which results in the nonspecific stimulation of a large percentage (>20%)
of total T cells and the massive release of inflammatory cytokines (eg, IL-1, IL-2, TNF-alpha &
beta, interferon-gamma). Cytokine release mediates the major manifestations of TSS including
fever, increased capillary permeability, and hypotension.
Exhibit Display
(Choice A) Endotoxin in the cell membrane of gram-negative bacteria can cause rapid-onset
fever and hypotension due to activation of toll-like receptors on cells of the innate immune
system. However, in this case, the presence of nasal packing and a diffuse, erythematous rash
make TSS far more likely than gram-negative sepsis.
(Choice C) Anaphylactic shock occurs due to antigen-stimulated cross-linking of IgE that is
bound to basophils or mast cells, which activates the cell and releases massive amounts of
inflammatory mediators. Anaphylactic shock is typically characterized by hypotension,
bronchospasm, and shortness of breath; most cases are triggered by insect stings, food, or
medications, and manifestations occur shortly after exposure.
(Choice D) Patients who develop TSS usually have a noninvasive infection in the vaginal canal
or area of wound packing. TSS is mediated by the absorption of superantigens into the blood,
not the invasion of bacteria.
Toxic shock syndrome is typically associated with the prolonged use of tampons or wound
Toxic shock syndrome is typically associated with the prolonged use of tampons or wound
packing, which allows Staphylococcus aureus to replicate locally and release pyrogenic toxic
superantigens (eg, toxic shock syndrome toxin-1) into the blood. Superantigens bind to the
MHC-II complex of antigen-presenting cells without processing and nonspecifically activate T
cells. This leads to a dramatic release of inflammatory cytokines, which causes the
manifestations of the disease (eg, hypotension; high fever; organ failure; diffuse, erythematous
rash).
4
A 24-year-old female presents to your office with burning urination, urgency and
frequency. She is sexually active. Urine cultures show catalase-positive, gram-positive
cocci. The organism responsible for this patient's symptoms is most likely to be:
Coagulase positive [15%]

A.
Hemolytic [6%]
B.
Novobiocin resistant [72%]
C.
DNase positive [2%]

D.
Yellow pigment producer [4%]

E.
The Staphylococci are Gram-positive cocci that form clusters, pairs and, rarely, short
chains. The catalase test (with 3% hydrogen peroxide) differentiates Streptococci (catalase-
chains. The catalase test (with 3% hydrogen peroxide) differentiates Streptococci (catalase-
negative) from Staphylococci (catalase-positive). The ability to clot blood plasma (slide and
tube coagulase tests) separates Staphylococci into two groups: the coagulase-positive
Staphylococci, which constitutes the most pathogenic species Staphylococcus aureus, and
coagulase-negative staphylococci (CNS), which constitutes S. epidermidis, S. Saprophyticus, S.
haemolyticus, and 30+ other species. The coagulase-negative staphylococci exist as part of the
normal flora on the skin and in the throat and nose, and only some species can cause infections.
S. saprophyticus is a common cause of urinary tract infection; it is responsible for almost half of
all UTIs in sexually active young women. S. saprophyticus is resistant to novobiocin. When
catalase-positive, coagulase-negative gram-positive cocci in clusters are isolated from urine
specimens of the above group of patients, the laboratory performs a novobiocin test to
distinguish this organism from other similar pathogens.
(Choice A) Coagulase positivity is a characteristic of S. aureus; this is how S. aureus is
differentiated from the other species of Staphylococci that do not express coagulase.
(Choice B) Hemolysis is a typical feature of Streptococci (streptolysin O and streptolysin S) and
Staphylococcus aureus (hemolysin). S. saprophyticus does not cause hemolysis.
(Choice D) DNase is produced by group A streptococcus. DNase degrades DNA in pus to
facilitate spread of the organism. Anti DNase can be used as a laboratory test in patients who
have had streptococcal infection followed by glomerulonephritis. DNase is not produced by S.
saprophyticus.
(Choice E) Yellow pigment is produced by Staphylococcus aureus. Staphylococcus
aureus usually does not cause urinary tract infections. If S. aureus is cultured from the urine
you should suspect a metastatic infection from another location in the body (an abscess or
infective endocarditis etc.)
S saprophyticus is responsible for almost half of all UTIs in sexually active young
women. Staphylococcus saprophyticusbelongs to coagulase negative staphylococci and is
unique among these because it is resistant to novobiocin.
5
A 40-year-old woman comes to the emergency department due to malaise, fever, productive
cough, and pleuritic chest pain. The patient has a history of alcohol abuse and HIV acquired
from injection drug use. She is nonadherent with antiretroviral therapy and other HIV-related
medications. Temperature is 38.3 C (101 F), blood pressure is 120/72 mm Hg, and pulse is
104/min. Lung examination reveals bronchial breath sounds and crackles. Sputum microscopy
findings are shown below.
Which of the following pathogenic factors most likely contributes to this microorganism's ability
to cause lung infection?
Alveolar hyaline membrane formation [3%]

A.
Antiphagocytic microbial capsule [72%]
B.
Endotoxin-induced cell necrosis [4%]

C.
Intracytoplasmic location of the organism [11%]

D.
Lipid-rich microbial cell wall [8%]
E.
Streptococcus pneumoniae is a gram-positive, lancet-shaped organism that grows in pairs

(diplococci). It colonizes the nasopharynx and is a leading cause of community-acquired
pneumonia, bacterial meningitis, sinusitis, otitis media, and sepsis. Patients with HIV have
increased susceptibility, as the virus dramatically hampers the production of opsonizing
antibodies and the recruitment of phagocytes to areas of infection.
The major virulence factor of S pneumoniae is a thick polysaccharide capsule, which impedes
phagocytosis and complement binding. Antibodies against the capsule form during infection
and are protective against future infections with that strain. However, over 90 capsular
serotypes have been identified. Therefore, patients at high risk of pneumococcal infection
(eg, HIV, extremes of age) should receive the pneumococcal vaccine, which contains
polysaccharide antigens from the most common strains.
Other S pneumoniae virulence factors include IgA protease (inactivates secretory IgA), adhesins
(necessary for adhesion to epithelial cells), and pneumolysin (a cytotoxin that causes pores in
cell membranes and cell lysis).
(Choice A) Alveolar hyaline membranes are fibrinous deposits that line the alveoli and inhibit
gas transfer. They usually result in significant dyspnea and/or respiratory collapse, and are
typically seen with infantile respiratory distress syndrome and acute respiratory distress
syndrome.
(Choice C) Endotoxins (eg, lipopolysaccharide) are found in the outer membrane of gram-
negative pathogens (eg, Neisseria) and produce a strong inflammatory response when released
into the circulation. Gram-positive organisms do not have endotoxins but some release
exotoxins.
(Choice D) Intracellular organisms such as Neisseria, Listeria, and Mycobacterium
tuberculosisare protected from immunoglobulin and complement binding. S pneumoniae is an
extracellular pathogen.
(Choice E) Mycobacteria have lipid-rich mycolic acid in their cell walls, which causes them to be
acid-fast. Mycolic acids inhibit bacterial destruction by the phagolysosome and contribute to
granuloma formation.
The virulence of Streptococcus pneumoniae is predominantly due to its polysaccharide capsule,
which impedes phagocytosis and complement binding.
6
A 6-month-old boy is brought to the ER with poor feeding and irritability. Physical examination
reveals diffuse skin erythema. You also notice that the epidermis easily comes off with gentle
pressure. Which of the following is the most likely cause of this patient's symptoms?
Microbial skin invasion [2%]

A.
Endotoxin-mediated inflammatory response [12%]

B.
Exotoxin-mediated skin damage [70%]
C.
Mast cell degranulation [2%]

D.
Cell-mediated hypersensitivity [11%]

E.
Staphylococcal Scalded Skin Syndrome (SSSS) is caused by certain strains of Staphylococcus

species that produce the exfoliatin exotoxin. Nikolsky's sign (skin slipping off with gentle
pressure), epidermal necrolysis, fever and pain associated with the skin rash are the major
symptoms of SSSS. SSSS is most common in infants and young children, and it is frequently not
fatal unless the skin lesions become secondarily infected.
Exfoliative toxins show exquisite pathologic specificity in blistering only the superficial
epidermis ("epidermolytic"). They act as proteases and cleave desmoglein in
desmosomes. Bullous impetigo is a more localized form of SSSS with the bulla formation being
another effect of exfoliative toxin.
(Choice A) Examples of microbial skin invasion include impetigo, folliculitis, furuncles,
carbuncles, and abscesses. SSSS is caused by a circulating exotoxin; the bacterial focus
producing the exotoxin can lie anywhere in the body.
(Choice B) Endotoxin-mediated inflammatory response is frequently the cause of septic shock
during gram-negative as well as some gram-positive infections (Listeria). The
lipopolysaccharide fragment "Lipid A" in gram-negative bacteria is a component of the cell
membrane and is not actively secreted from the cell as exotoxins are. It is released by
bacteriolysis during antibiotic treatment or immune-mediated mechanisms. Exfoliatin is
an EXOtoxin, not an ENDOtoxin.
(Choice D) Mast cell degranulation is mediated by crosslinking of membrane-bound IgE on the
surface of mast cells. This is a component of Type 1 hypersensitivity, or atopy. Conditions
caused by this form of hypersensitivity include food allergies, asthma, atopic dermatitis, and
allergic rhinitis.
(Choice E) Cell-mediated hypersensitivity, or Type IV delayed-type hypersensitivity, is mediated
(Choice E) Cell-mediated hypersensitivity, or Type IV delayed-type hypersensitivity, is mediated
by sensitized TH1 cells that secrete cytokines attracting macrophages to a local area. This is the
mechanism of many contact dermatitis reactions as well as positivity of the skin tests for
tuberculosis exposure (PPD) and for anergy (candida antigen).
The staphylococcal scalded skin syndrome occurs in infants and children due to the production
of the exotoxin exfoliatin by Staphylococcus species. It causes widespread epidermal sloughing,
especially with gentle pressure (Nikolsky's sign).
7
A microbiologist is studying the structure and function of bacterial cell walls. In an experiment,
group A streptococci are treated with chemicals to solubilize the cell wall. Various cell wall–
associated proteins are subsequently extracted. Electron microscopic evaluation of a specific
protein shows structural homology with mammalian tropomyosin and myosin. This protein
acts as a virulence factor for certain species of the organism. Which of the following is the most
likely function of this bacterial cell wall–associated protein?
Excrete antibiotics [5%]

A.
Protect from osmotic lysis [7%]

B.
Provide mechanical cell support [31%]

C.
Resist phagocytosis [46%]
D.
Transport nutrients into the cell [8%]

E.
Gram-positive organisms have cell walls composed primarily of a thick peptidoglycan layer and
teichoic acid. However, additional cell wall components are often present that contribute to
virulence, motility, or the ability to adhere to epithelial surfaces. For instance, the cell wall
of group A streptococcus (also known as Streptococcus pyogenes) is studded with M protein, a
virulence factor that inhibits phagocytosis, prevents complement binding, and aids in epithelial
attachment.
M protein is an alpha-helical coiled-coil protein that shares epitopes and structural homology
with other alpha-helical coiled-coil proteins such as tropomyosin and myosin. In some
patients, the protective antibodies against M protein that develop in S pyogenes acute infection
may cross-react with myosin epitopes in the heart and cause rheumatic carditis.
Exhibit Display
(Choice A) Efflux pumps are generally globular proteins with multiple domains. They reside in
the bacterial cell membrane and excrete toxic substances from the interior of the cell. Bacteria
can use efflux pumps to generate antibiotic resistance to drugs that operate in the interior of
the cell, such as fluoroquinolones and aminoglycosides.
(Choices B and C) The bacterial cell wall of S pyogenes provides mechanical support and
protects it from osmotic lysis. It is composed primarily of peptidoglycan, which forms a mesh-
like, cross-linked polymer of peptides and sugars.
Exhibit Display
(Choice E) Porins in the cell membrane aid in the movement of nutrients into bacterial
cells. They are composed of protein strands that group together to form a barrel (beta-barrel).
The major virulence factor of Streptococcus pyogenes is M protein, an alpha-helical coiled-coil
protein that shares structural homology with tropomyosin and myosin. It extends from the cell
wall and prevents phagocytosis, inhibits complement binding, and mediates bacterial
adherence. Antibodies against M protein form shortly after acute infection and may cross-react
with epitopes on myosin, leading to rheumatic carditis.
8
A 2-day-old newborn develops lethargy and respiratory distress. Blood cultures grow beta-
hemolytic Gram-positive cocci in chains that are bacitracin-resistant. Which of the following
measures could have prevented this patient's condition most effectively?
Penicillin at 30 weeks gestation [27%]

A.
Maternal vaccination [12%]

B.
Intrapartum ampicillin [50%]
C.
Postnatal immunoglobulin [6%]

D.
Breast feeding restriction [2%]

E.
The finding of Gram-positive cocci in chains indicates Streptococcus as Staphylococci classically

form clusters. Group A Streptococci and Group B Streptococci are beta-hemolytic, but
bacitracin resistance excludes S. pyogenes (GAS) and indicates S. agalactiae (GBS).
The 2002 guidelines for perinatal group B strep prevention recommend universal prenatal
screening for group B streptococcal colonization by maternal vaginal and rectal culture at 35-37
weeks gestation. In women who culture positive for GBS or in women who have had an infant
affected by GBS in the past, intrapartum antibiotic prophylaxis is indicated to prevent neonatal
GBS sepsis, pneumonia and meningitis. The incidence of group B streptococcal disease in
babies less than a week old is declining due to these recommendations.
Penicillin remains the first line agent for intrapartum antibiotic prophylaxis, with ampicillin an
acceptable alternative.
(Choice A) Use of penicillin G at 30 weeks gestation would serve to eliminate GBS at that time
and likely for the next few weeks in the expecting mother. However, after approximately 4
weeks depending on the dose administered, she is again vulnerable to colonization with
GBS. Treatment with antibiotics this early in pregnancy is ineffective for GBS prophylaxis.
(Choice B) Theoretically, immunization of women during or before pregnancy could prevent
peripartum maternal disease and protect infants from perinatally acquired infection by
transplacental transfer of protective IgG antibodies. This would eliminate the need for prenatal
GBS screening and intrapartum antimicrobial prophylaxis in women with a clear vaccination
history. Serotype-specific antibodies to GBS capsular polysaccharide have been shown to
protect against disease, but as yet a vaccine is not available against GBS, so this can not be the
correct answer. Vaccines are currently being developed against the capsular polysaccharide of
GBS.
GBS.
(Choice D) Administration of postnatal immunoglobulin in newborns suffering from GBS
infections has been studied with no true demonstration of efficacy. It is not widely used in
clinical practice.
(Choice E) Breast feeding should not be restricted under normal circumstances because the
human milk, especially the colostrum, provides some mucosal immune protection to the
newborn. Additionally, breast feeding is recommended by the American Academy of Pediatrics
as the sole source of nutrition for all infants for the first six months due to its superior
nutritional content, its ability to promote the proper development of the infant GI tract, and
the immune protection afforded by agents such as IgA in human breast milk.
Universal prenatal screening for group B strep colonization by vaginal-rectal culture at 35-37
weeks gestation is recommended to identify colonized women who require INTRAPARTUM
antibiotics, most frequently with penicillin or ampicillin, to prevent neonatal GBS sepsis,
pneumonia and meningitis.
9
A 52-year-old man is hospitalized due to 2 weeks of low-grade fever, malaise, anorexia, and
fatigue. The patient has a history of bicuspid aortic valve and underwent aortic valve
replacement a year ago. Physical examination reveals a new regurgitation murmur. Blood
cultures repeatedly grow gram-positive cocci in clusters, which are identified as Staphylococcus
epidermidis. This pathogen most likely demonstrates which of the following characteristics?
Alpha hemolysis [3%]

A.
Mannitol fermentation [2%]

B.
Negative catalase test [6%]

C.
Negative coagulase test [78%]
D.
Novobiocin resistance [8%]

E.
Yellow pigment production [1%]

F.
Staphylococcus epidermidis is a low-virulence skin commensal that rarely causes infection in

healthy patients. However, those with prosthetic devices (eg, indwelling catheters, artificial
heart valves, artificial joints) are at risk because the pathogen produces adhesion and biofilm
proteins that allow it to grow on artificial surfaces. S epidermidis is one of the most common
contaminants of blood cultures, but infection should be suspected when multiple blood
cultures grow the bacteria and/or the patient has symptoms of clinical infection such as fever,
malaise, and leukocytosis.
Staphylococcus species are gram-positive cocci that grow in grape-like clusters. They are
differentiated from streptococci by the catalase test: Streptococci are catalase-negative
whereas staphylococci are catalase-positive (Choice C). Further speciation of staphylococci
leverages the coagulase test (the ability to clot blood plasma), which differentiates S
aureus from coagulase-negative staphylococci such as S epidermidis, S haemolyticus, and S
saprophyticus.
Exhibit Display
(Choice A) Alpha hemolysis (partial, green hemolysis when plated on blood agar) is a feature of
viridans streptococci, a common cause of infective endocarditis. Staphylococci species are
either beta-hemolytic (complete hemolysis) or gamma-hemolytic (no hemolysis). S
epidermidis is gamma-hemolytic.
(Choice B) S aureus and S haemolyticus can ferment mannitol, but S epidermidis cannot.
(Choice E) Novobiocin is an antibiotic that can be applied to plated colonies to differentiate S
saprophyticus from other coagulase-negative Staphylococcus species: S saprophyticus is
novobiocin-resistant whereas others, such as S epidermidis, are novobiocin-sensitive.
(Choice F) S aureus produces a golden-yellow surface pigment, which accounts for its name
(aureus means gold in Latin). S aureus is a common cause of infective endocarditis and
osteomyelitis, particularly in intravenous drug users.
Staphylococcus epidermidis, a gram-positive coccus that grows in clusters, is a skin commensal
that is a common cause of infection in patients with prosthetic devices such as artificial joints or
heart valves. Unlike S aureus, S epidermidis is coagulase-negative. Unlike S
saprophyticus (another coagulase-negative staphylococci species), S epidermidis is susceptible
to novobiocin.
10
A 78-year-old man is brought to the emergency department due to fever, cough, and shortness
of breath. The patient recently moved into an assisted living facility after living with his family
that owned several pets. He has a 40-pack-year smoking history. Temperature is 39.4 C (103
F), blood pressure is 106/62 mm Hg, pulse is 112/min, and respirations are 28/min. There is
dullness to percussion and bronchial breath sounds over the left lung. Chest x-ray reveals a left
lower lobe consolidation. Sputum microscopy shows gram-positive diplococci. Which of the
following would have been most helpful in preventing this patient's lung infection?
Avoidance of exposure to bird droppings [3%]

A.
Immediate chemoprophylaxis after exposure [3%]

B.
Immunization with inactivated microbial agent [12%]

C.
Periodic culture and disinfection of water supply [2%]

D.
Vaccination with bacterial polysaccharide [79%]
E.
This patient with fever, pulmonary symptoms, and a lobar consolidation on chest x-ray
has pneumonia. The presence of gram-positive diplococci in the sputum indicates the
underlying pathogen is Streptococcus pneumoniae, the leading cause of community-acquired
pneumonia. Over 90 strains of S pneumoniae have been identified; they are distinguished
based on antigenic variations in the capsular polysaccharide, the major virulence factor of the
bacteria. Antibodies against the polysaccharide capsule are generated during infection and
provide long-lasting immunity against that strain.
The pneumococcal vaccine contains polysaccharide antigens from the most common disease-
causing serotypes leading to the generation of protective antibodies against these strains. In
the United States, 2 types of pneumococcal vaccinations are available:
1. Pneumococcal polysaccharide vaccine contains capsular material from 23
serotypes. Because polysaccharides cannot be displayed by the major histocompatibility
complex of antigen-presenting cells (only peptides can), immunogenicity to this vaccine is
T-cell independent and driven largely by B-cell activation. This leads to a moderate
antibody response that is effective for most patients but not infants (age <2).
2. Pneumococcal conjugate vaccine consists of capsular polysaccharides from 13 serotypes
that have been covalently attached to recombinant, inactivated diphtheria toxin. Protein
that have been covalently attached to recombinant, inactivated diphtheria toxin. Protein
conjugation allows the polysaccharide to be displayed by the major histocompatibility
complex and induces a stronger immunogenic response that involves T-cell–mediated B-
lymphocyte activation. This generates higher- affinity antibodies and memory cells and
also creates mucosal antibodies, which reduce colonization rates.
Pneumococcal vaccination significantly reduces the risk of invasive pneumococcal
disease. Routine vaccination is recommended for all children as part of their childhood
immunization series. Adults age >65 and those at high risk for invasive disease (eg, HIV,
asplenia, other immunosuppressed states) should also be vaccinated.
(Choice A) Histoplasma is a fungal infection that is primarily transmitted by inhalation of
particles from soil contaminated with bird or bat droppings. Diagnosis is usually made by urine
or serum antigen testing, but yeasts can sometimes be identified on histology/culture using
specialized stains.
(Choice B) Close contacts of patients who have pertussis should be given antibiotic
chemoprophylaxis. Pertussis is a gram-negative encapsulated coccobacillus; infected adults
usually develop a few weeks of malaise and rhinorrhea followed by several weeks of severe,
paroxysmal cough.
(Choice C) The influenza vaccine contains 3 or 4 strains of inactivated influenza virus. Influenza
usually causes abrupt-onset fever, headache, myalgia, and malaise and would not appear on
Gram stain.
(Choice D) Legionella is a common cause of atypical pneumonia and is usually transmitted by
contaminated water systems. However, Legionella is a gram-negative bacterium (not a gram-
positive diplococcus) and is usually diagnosed with urine antigen testing.
Streptococcus pneumoniae vaccination reduces the risk of invasive disease and is
recommended for young patients and the elderly. The pneumococcal polysaccharide vaccine is
an unconjugated vaccine that induces a T-cell–independent humoral immune response. In
contrast, the pneumococcal conjugate vaccine contains polysaccharide material attached to a
protein antigen, which creates a robust T-cell–mediated humoral immune response.
11
A 62-year-old man comes to the emergency department due to the sudden onset of high fever,
shaking chills, shortness of breath, and productive cough. The patient has smoked a pack of
cigarettes daily for 40 years. Examination shows dullness to percussion over the left side of the
chest. Chest x-ray reveals consolidation in the left upper lobe. Gram stain of the sputum shows
numerous polymorphonuclear leukocytes and gram-positive cocci in pairs. When cultured on a
blood agar plate under aerobic conditions, the bacterial colonies are surrounded by a zone of
incomplete hemolysis. The major virulence factor of these bacteria is responsible for which of
the following pathogenic features?
Inhibition of host protein synthesis [2%]

A.
Motility within host tissue [1%]

B.
Prevention of phagosome-lysosome fusion [5%]

C.
Resistance to phagocytosis [86%]
D.
Survival in extreme environments [3%]

E.
Lobar pneumonia typically presents with acute-onset fever, cough, and lobar consolidation on
chest x-ray. Although a number of different bacterial pathogens cause lobar pneumonia
(eg, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus), the most common
cause is Streptococcus pneumoniae.
Exhibit Display
S pneumoniae is a gram-positive diplococci that exhibits partial (α) hemolysis on blood agar
(green colonies) and is bile-soluble and Optochin-sensitive. Its major virulence factor is a
thick polysaccharide capsule that encases the organism and prevents phagocytosis and
complement binding. Under the microscope, the capsule swells and appears as a halo around
the blue-stained bacterial cells when specific anti-capsular antibodies and methylene blue dye
are added ("quellung reaction").
Exhibit Display
Exhibit Display
Infection with S pneumoniae leads to the generation of anti-capsular antibodies that are
protective against future infection with that strain. However, over 90 different antigenic
variations (serotypes) of capsular polysaccharides have been identified, so future infection can
occur with a strain that has not yet been encountered. Therefore, patients at high risk for
invasive pneumococcal disease (eg, HIV, extremes of age) are generally given the
pneumococcal vaccine, which induces immunity against the most common strains.
Other virulence factors of S pneumoniae include IgA protease (inactivates secretory IgA),
adhesins (necessary for adhesion to epithelial cells), and pneumolysin (cytotoxin that causes
pores in cell membranes and cell lysis).
(Choice A) Certain bacterial exotoxins (eg, Shiga toxin) enter the host cell and cleave a
nucleobase from the host ribosome, thereby inhibiting host protein synthesis. Others (eg,
diphtheria toxin) prevent protein elongation. S pneumoniae does not directly inhibit host
diphtheria toxin) prevent protein elongation. S pneumoniae does not directly inhibit host
protein synthesis.
(Choice B) Motility within host tissue can be provided by flagella. S pneumoniae is a nonmotile
organism.
(Choice C) Facultative intracellular bacteria such as Mycobacterium tuberculosis and Listeria
monocytogenes have virulence factors that prevent the bacteria from being destroyed by the
phagolysosome of macrophages. S pneumoniae is not an intracellular pathogen.
(Choice E) Spores are resistant to chemical disinfectants, irradiation, desiccation, and
temperatures as high as 120 C (248 F). Bacillus and Clostridium species commonly produce
spores, but S pneumoniae does not.
The primary virulence factor of Streptococcus pneumoniae is a polysaccharide capsule that
inhibits opsonization and phagocytosis. The polysaccharide capsule of the most virulent strains
is targeted by the pneumococcal vaccine, which confers immunity against those subtypes.
12
A 23-year-old woman comes to the hospital due to fever, chills, dyspnea, and cough for the past
several days. She also has sharp right-sided chest pain exacerbated by breathing. Her
temperature is 39 C (102 F), blood pressure is 115/70 mm Hg, and pulse is 108/min. On
examination, the patient has several needle track marks on both arms. There is a 3/6
holosystolic murmur heard best at the lower sternal border that increases on inspiration. Chest
imaging reveals scattered bilateral peripheral lung opacities. HIV testing is negative. This
patient's blood cultures are most likely to grow which of the following organisms?
Candida albicans [1%]

A.
Eikenella corrodens [0%]

B.
Klebsiella pneumoniae [1%]

C.
Nocardia asteroides [0%]

D.
Peptostreptococcus [0%]
E.
Staphylococcus aureus [88%]
F.
Streptococcus gallolyticus (formerly S bovis) [0%]

G.
Streptococcus pneumoniae [1%]

H.
Viridans group streptococcus [4%]

I.
Staphylococcus aureus can cause right-sided endocarditis in intravenous drug users(IVDUs). In
patients other than IVDUs, S aureus disseminates from a primary disease process (eg, abscess,
infected central line) and moves by hematogenous spread to the endocardium. S aureus settles
on the valve leaflets due to blood flow turbulence at these sites. S aureus can cause
perforations in the heart valves, rupture the chordae tendineae, and send septic emboli to the
lung (with right heart endocarditis) or to the brain and systemic circulation (with left heart
endocarditis). This patient with fever is an IVDU with a holosystolic murmur that increases with
inspiration (likely tricuspid regurgitation) and multiple lung opacities (likely septic emboli). She
likely has S aureusendocarditis.
(Choice A) Candida endocarditis (rare) is typically a severe manifestation of candidemia, with
septic emboli to the brain, extremities, and gastrointestinal tract. Patients who are IVDUs, have
septic emboli to the brain, extremities, and gastrointestinal tract. Patients who are IVDUs, have
prosthetic heart valves, or have indwelling lines are at increased risk of infection.
(Choice B) Culture-negative endocarditis - due to Bartonella, Coxiella, Mycoplasma,
Histoplasma, Chlamydia, or the HACEK organisms
(Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella), among others - would
be much less likely than S aureus endocarditis.
(Choices C, D, E, and H) Streptococcus pneumoniae and Klebsiella pneumoniae typically cause
pneumonia; Klebsiella can also lead to urinary tract infections. Nocardiosis typically affects the
lungs (cavitary lesions), brain (brain abscess), or skin and is seen mostly in
immunocompromised patients. Peptostreptococcus causes anaerobic infections (dental,
cutaneous, intraabdominal).
(Choice G) Streptococcus gallolyticus (formerly S bovis) is a part of the normal flora of the
colon, and bacteremia or endocarditis caused by S bovis is associated with colon cancer (~25%
of cases).
(Choice I) Streptococcus viridans is the most common etiologic agent in subacute bacterial
endocarditis (SBE) following dental work. SBE occurs most frequently in patients with a
preexisting valvular abnormality (eg, rheumatic heart disease, congenital heart
malformations). The presentation is typically subacute (over weeks rather than days).
Staphylococcus aureus causes acute bacterial endocarditis with rapid onset of symptoms,
including shaking chills (rigors), high fever, dyspnea on exertion, and malaise. In intravenous
drug users, it can cause right-sided endocarditis with septic embolization into the lungs.
13
A 65-year-old man comes to the emergency department due to abdominal pain and
diarrhea. Three weeks ago, he drove from Texas to Mexico for a family vacation. Temperature
is 38.3 C (101 F), blood pressure is 115/70 mm Hg, and pulse is 98/min. Abdominal examination
shows mild, generalized tenderness with no rebound tenderness or guarding. Leukocyte count
is 14,000/mm3. Sigmoidoscopy demonstrates white-yellow plaques on the colonic mucosa, and
biopsy shows that the plaques are composed of fibrin and inflammatory cells. Further
questioning regarding this patient's trip to Mexico is most likely to reveal which of the following
events?
He consumed shellfish from the hotel buffet [4%]

A.
He drank unpurified tap water on several occasions [14%]

B.
He had undercooked pork at a resort barbecue [6%]

C.
He required hospitalization and antibiotics for pneumonia [74%]
D.
He took home-canned foods to consume during the trip [1%]

E.
This patient has abdominal pain, diarrhea, and leukocytosis. The formation
of pseudomembranes (white-yellow plaques composed of fibrin, inflammatory cells, and
cellular debris) on the colonic mucosa is highly consistent with pseudomembranous colitis due
to Clostridium difficile, a spore-forming bacillus that colonizes up to 50% of hospitalized
adults. Antibiotic therapy (eg, fluoroquinolones for bacterial pneumonia) increases the
risk of C difficile infection as it kills intestinal microbes that normally keep potential pathogens
in check. C difficile can proliferate in the altered microbiome, leading to overgrowth and clinical
disease.
Exhibit Display
C difficile produces 2 toxins—toxin A (enterotoxin) and toxin B (cytotoxin)—which penetrate
C difficile produces 2 toxins—toxin A (enterotoxin) and toxin B (cytotoxin)—which penetrate
colonic epithelial cells and damage cellular cytoskeletons and intercellular tight junctions. This
results in widespread inflammation, edema, necrosis, and fibrin deposition. Clinical
manifestations range from watery diarrhea and mild abdominal cramping to fulminant colitis
with nonobstructive colonic enlargement (megacolon) and intestinal perforation.
(Choices A and B) Ingestion of undercooked shellfish is associated with Vibrio, Norwalk virus,
and hepatitis A infections. Traveler's diarrhea, caused by bacteria (eg,
enterotoxigenic Escherichia coli, Campylobacter, Salmonella, Shigella) or parasites (eg, Giardia),
is often due to contaminated water consumption. These conditions can manifest as diarrhea
and abdominal pain; however, pseudomembranes are virtually pathognomonic for C
difficile colitis.
(Choice C) Consumption of undercooked pork is a risk factor for intestinal tapeworm
(taeniasis), which occurs after ingestion of Taenia solium. Patients are often asymptomatic but
may have nausea or abdominal pain.
(Choice E) Adult botulism occurs after ingestion of preformed toxin in home-canned food. This
neurotoxin inhibits acetylcholine release from the nerve terminals at neuromuscular junctions
and causes a descending flaccid paralysis.
Antibiotics disrupt the normal intestinal flora and which can allow for overgrowth
of Clostridium difficile, an anaerobic, gram-positive, spore-forming bacillus. C difficile produces
2 toxins that penetrate colonic epithelial cells leading to watery diarrhea, abdominal cramping,
and colitis. The presence of a pseudomembrane (exudate on colonic mucosa consisting of
fibrin and inflammatory cells) is highly suggestive of C difficile infection.
14
A 4-year-old boy is brought to the emergency department with dehydration. He has had
several days of decreased oral intake, and today his parents could not get him to drink
anything. The patient has received no vaccinations due to parental beliefs. Vital signs are
normal except for mild tachycardia. Physical examination shows decreased skin turgor and
sunken eyes. His jaw muscles are tight. Neurologic examination shows increased tone
throughout and 3+ patellar reflexes. There is a small, healed puncture wound on his lower
leg. The father says that the boy fell on a piece of chain-link fence in their backyard last
week. Release of which of the following neurotransmitters is most likely to be directly impaired
in this patient?
Acetylcholine [28%]
A.
Dopamine [1%]
B.
Glutamate [13%]
C.
Glycine [56%]
D.
Serotonin [0%]
E.
This unvaccinated child has evidence of tetanus (Clostridium tetani infection) following a
puncture wound. C tetani causes disease not through tissue invasion but by producing a potent
metalloprotease exotoxin (tetanospasmin) that is deadly in nanogram quantities. The toxin
first binds to receptors on the presynaptic membranes of peripheral motor neurons. From
there, it migrates by retrograde axonal transport to central inhibitory neurons in the spinal
cord and brain stem and prevents release of the inhibitory
neurotransmitters glycine and gamma-aminobutyric acid (GABA). Suppression of inhibitory
nerve activity results in increased activation of motor nerves, causing muscle
spasms and hyperreflexia. Classic features include difficulty opening the jaw (lockjaw,
or trismus), a fixed sardonic smile (risus sardonicus), and contractions of back muscles resulting
in backward arching (opisthotonos). Patients are also extremely irritable and develop tetanic
spasms in response to minor stimuli such as loud noises.
(Choice A) Acetylcholine release is inhibited by the botulinum toxin from C botulinum, leading
to the flaccid paralysis seen in clinical botulism.
(Choices B and C) Neither dopamine nor glutamate release has been linked to toxin effects in
humans.
(Choice E) Serotonin release from enterochromaffin cells in the gastrointestinal tract is
stimulated by Vibrio cholera enterotoxin. This increased serotonin release contributes to the
extreme fluid secretion seen in cholera.
Tetanospasmin is a neuro-exotoxin released by Clostridium tetani. The toxin blocks the release
Tetanospasmin is a neuro-exotoxin released by Clostridium tetani. The toxin blocks the release
of glycine and gamma-aminobutyric acid (GABA) from the spinal inhibitory interneurons that
regulate the lower motor neurons. These disinhibited motor neurons cause increased
activation of muscles, leading to spasms and hyperreflexia.
15
A 27-year-old man comes to the emergency department due to several hours of right foot pain
and swelling. Last night, he was working in the barn and stepped on an old nail. This morning,
the patient awoke with right foot pain near the injury site that has increased throughout the
day and is accompanied by progressive swelling. He has no significant past medical history and
takes no medications. Temperature is 38.1 C (100.6 F), blood pressure is 135/75 mm Hg, and
pulse is 95/min. The right foot is swollen with some erythema around the injury
site. Radiographic imaging reveals gas in the tissues. On urgent surgical exploration, extensive
tissue necrosis is present. Culture from the site reveals gram-positive rods. Which of the
following best describes the mechanism of action of the toxin responsible for the necrotic
effects seen in this patient?
Actin depolymerization [8%]

A.
Carbohydrate degradation [7%]

B.
Elongation factor ribosylation [10%]

C.
Phospholipid splitting [61%]
D.
Plasminogen activation [1%]

E.
Presynaptic acetylcholine release [7%]

F.
T cell hyperstimulation [2%]

G.
This patient likely has gas gangrene due to Clostridium perfringens (toxin-producing gram-
positive rods). Lecithinase is the main toxin of C perfringens; its concentration correlates with
its lethal and necrotic effects. Lecithinase, also known as phospholipase C or alpha
toxin, catalyzes the splitting of phospholipid molecules. It hydrolyzes lecithin-containing
lipoprotein complexes in cell membranes, causing cell lysis (including erythrocyte hemolysis),
tissue necrosis, and edema. (In contrast, human phospholipase A2 catalyzes arachidonic acid
release from phospholipid cell membranes in the first step of leukotriene, thromboxane, and
prostaglandin synthesis.) C perfringens has at least 12 toxins, of which phospholipase C is the
most injurious.
C perfringens uses carbohydrates for energy. Its rapid metabolism of muscle tissue
carbohydrates produces significant amounts of gas, which can be demonstrated
radiographically by plain film x-ray or CT scan (Choice B).
(Choices A and F) Actin depolymerization and inhibition of presynaptic acetylcholine release
are the mechanisms of action of C difficile cytotoxin B and C botulinum botulinum toxin,
respectively.
(Choice C) Inactivation of elongation factor-2 through ribosylation describes the mechanism of
action for diphtheria toxin.
(Choice E) Plasminogen activators such as streptokinase, urokinase, and tissue plasminogen
activator convert plasminogen to plasmin. Of these 3 enzymes, only streptokinase - an exotoxin
released by Streptococcus pyogenes (group A Streptococcus) - is a bacterial product.
(Choice G) Certain Staphylococcus aureus-produced toxins act as superantigens by
hyperstimulating T cells and causing massive cytokine production. Examples include
enterotoxin (causes food poisoning) and toxic shock syndrome toxin.
Lecithinase, also known as alpha toxin, is the main toxin produced by Clostridium
perfringens. Its function is to degrade lecithin, a component of cellular phospholipid
membranes, leading to membrane destruction, cell death, and widespread necrosis and
hemolysis.
16
Three cases of severe pharyngitis were reported in a community of immigrants. The patients
had thick pharyngeal exudates, neck swelling, and difficulty swallowing. One of them died from
severe heart failure. The toxin responsible has a mechanism of action most similar to another
toxin produced by which of the following bacteria?
Pseudomonas aeruginosa [57%]
A.
Staphylococcus aureus [9%]

B.
Clostridium difficile [7%]

C.
Clostridium botulinum [3%]

D.
Bordetella pertussis [16%]

E.
Vibrio cholerae [4%]

F.
Severe pharyngitis with exudates and cervical lymphadenopathy in a group of people with
unknown vaccination status should raise suspicion for respiratory diphtheria
infection. Diphtheria toxin can cause severe myocarditis and heart failure, which occurred in
one of the patients in the vignette. Diphtheria toxin acts in a similar manner to exotoxin A,
which is produced by Pseudomonas aeruginosa.
P aeruginosa produces several extracellular products, including exotoxin A, collagenase,
elastase, fibrinolysin, phospholipase C, and DNAse. These substances assist in its invasion and
dissemination in human tissues. Although they are structurally different, both diphtheria toxin
and exotoxin A ribosylate and inactivate elongation factor-2 (EF-2), halting human cell protein
synthesis and causing cell death. Exotoxin A is a major virulence factor and is responsible for
the high mortality associated with P aeruginosa septicemia.
Diphtheria toxin and pseudomonal exotoxin A act by ribosylating and inactivating elongation
factor-2, inhibiting host cell protein synthesis and causing cell death.
17
An 8-year-old boy is brought to the office for rapid and irregular movements of his hands for
one week. His parents say that he is also making unintentional "funny faces" and has trouble
controlling the volume of his voice. His temperature is 38.9 C (102 F). On physical examination,
the boy moves his hands frequently and erratically. He has a new III/VI systolic murmur and
several circular, faintly erythematous lesions on his abdomen. Which of the following is the
most likely mechanism for this patient's condition?
Nonspecific T cell receptor activation [4%]

A.
Cross-reactivity of antibodies against bacterial and host antigens [71%]
B.
Embolization of an infected thrombus [5%]

C.
Injury from immune complex deposition [8%]

D.
Release of an erythrogenic toxin [10%]

E.
This patient has acute rheumatic fever, an immune-mediated disease following an
untreated group A streptococcal (GAS) infection. Antibodies against GAS cross-react with host
tissues due to molecular mimicry between GAS antigens and cardiac and central nervous
system antigens. Specifically, antibodies directed against GAS antigens, M protein and N-
acetyl-beta-D-glucosamine, subsequently attack myosin, a cardiac protein, and lysoganglioside,
a neuronal cell surface protein.
The major manifestations of acute rheumatic fever include arthritis, pancarditis, Sydenham
chorea, erythema marginatum, and subcutaneous nodules. This patient's murmur is likely due
to acute mitral regurgitation from pancarditis. Sydenham chorea presents with non-rhythmic
movements of the hands, feet, and face. Patients often have sudden changes in voice pitch and
volume. Erythema marginatum presents as faintly erythematous, circular lesions with central
clearing that come and go on the trunk and extremities.
Exhibit Display
(Choice A) Superantigens cause a tremendous release of cytokines through nonspecific T cell
receptor activation, leading to acute fever, hypotension, and erythroderma. This is the
mechanism of action of the toxic shock syndrome exotoxins produced by both Staphylococcus
aureus and Streptococcus pyogenes.
(Choice C) An embolic stroke from infective endocarditis can present with fever, a new-onset
murmur, and focal neurologic deficits. In addition, Janeway lesions, Osler nodes, and Roth
spots are specific findings of infectious endocarditis. The most common pathogens are S
aureus, viridans group streptococci, and enterococci.
(Choice D) The deposition of streptococcal antigen immune complexes in glomeruli causes
post-streptococcal glomerulonephritis, a type III hypersensitivity reaction. Patients have
microscopic or gross hematuria, edema, hypertension, and proteinuria.
(Choice E) Scarlet fever is caused by the body's response to an erythrogenic (pyrogenic) toxin
released by group A Streptococcus. It presents with a diffuse, erythematous, "sandpaper"-
textured rash most notable in the skin folds (eg, inguinal, axillary, antecubital areas). Scarlet
fever can occur with pharyngitis and can lead to acute rheumatic fever if untreated.
Acute rheumatic fever is an autoimmune reaction following an untreated group A streptococcal
pharyngitis. Anti-group A Streptococcus antibodies (eg, anti-M protein, anti-N-acetyl-beta-D-
glucosamine) cross-react and attack cardiac and central nervous system antigens.
18
A 45-year-old man comes to the physician due to pain, swelling, and erythema affecting his
right leg. He says that he suffered a minor cut to his leg a few days ago while cleaning his
garage. Physical examination shows an indurated region surrounding a minor laceration that is
draining a purulent exudate. He is diagnosed with cellulitis and started on the appropriate
treatment. Gram stain of the exudate shows gram-positive cocci in clusters. The organism
most likely responsible for this patient's infection synthesizes a protein as part of its
peptidoglycan cell wall that does which of the following?
Activates complement [8%]

A.
Binds the Fc portion of IgG [56%]
B.
Causes hemolysis [11%]

C.
Cleaves IgA [15%]

D.
Interacts with MHC class II antigens [8%]

E.
Clusters of gram-positive cocci on Gram stain is a characteristic finding of staphylococcal
species such as Staphylococcus aureus. Protein A is a virulence factor that forms part of the
outer peptidoglycan layer of S aureus. Protein A binds with the Fc portion of IgG antibodies at
the complement-binding site, preventing complement activation (Choice A). This results in
decreased production of C3b, leading to impaired opsonization and phagocytosis.
(Choice C) Hemolysin is secreted by staphylococci and causes hemolysis as well as the
destruction of neutrophils, macrophages, and platelets. It is a secreted factor that is not bound
to the cell wall.
(Choice D) Streptococcus pneumoniae and Neisseria gonorrhoeae produce IgA proteases that
cause cleavage of IgA antibodies, preventing them from interfering with bacterial adhesion to
mucous membranes.
(Choice E) Major histocompatibility complex (MHC) class II (found on an antigen presenting
cells) normally interacts with processed antigens, presenting them to T-lymphocytes to initiate
an immune response. In contrast, superantigens (enterotoxins, toxic shock syndrome toxin)
interact with MHC class II and the T-cell receptor outside of standard antigen binding sites to
initiate widespread and nonspecific activation of T- lymphocytes. Although superantigens are
synthesized by staphylococci, they are not bound to the peptidoglycan cell wall.
Protein A is a virulence factor found in the peptidoglycan cell wall of Staphylococcus aureus that
binds to the Fc portion of IgG, leading to impaired complement activation, opsonization, and
binds to the Fc portion of IgG, leading to impaired complement activation, opsonization, and
phagocytosis.
19
A 79-year-old woman is brought to the emergency department from the nursing home due to
explosive diarrhea. Laboratory studies show leukocytosis, and results from a stool specimen
return positive for Clostridium difficile toxin genes by polymerase chain reaction. Three days
later, one of the nurses who cared for the patient at the nursing home is admitted with
diarrhea and is found to have C difficile infection. However, the other nurses who also took
care of the patient are asymptomatic and do not develop the infection. If all the nurses were
similarly exposed to C difficile, which of the following is the most likely reason that the
asymptomatic nurses did not develop the infection?
Adequate pancreatic enzyme secretion [0%]

A.
Intact cell-mediated immunity [5%]

B.
Preformed antispore immunoglobulins [5%]

C.
Preserved intestinal microbiome [84%]
D.
Rapid gastrointestinal transit and expulsion of spores [4%]

E.
Over 400 types of bacteria inhabit the healthy human gastrointestinal tract as part of the
normal intestinal microbiome. In healthy humans, these include very few aerobes
(eg, Pseudomonas), approximately 10% facultative anaerobes (eg, Escherichia coli, Klebsiella,
Lactobacillus, Bacillus), and a majority of strict anaerobes (eg, Bacteroides, Fusobacterium,
Clostridium). These intestinal bacteria effectively suppress overgrowth of Clostridium
difficile and other potentially pathogenic bacteria by competing for nutrients and adhesion
sites within the gut.
Antibiotic therapy is the most important risk factor for C difficile infection (CDI) as it can alter
the microbiome, leading to a potential overgrowth of pathogenic strains and clinical
disease. The organism causes disease by releasing 2 toxins that damage the mucosal lining of
the large intestine, leading to diarrhea (toxin A) and necrosis (toxin B) with pseudomembrane
formation.
(Choice A) Increased risk of CDI is seen with proton pump inhibitor use, suggesting that gastric
acidity may have a protective role. The pancreas secretes protease, amylase and lipase, and
trypsinogen, among others; however, there is no association between pancreatic enzyme
secretion and CDI.
(Choice B) Cell-mediated immunity is not essential for prevention of CDI, but it is required to
eradicate infections with intracellular agents that avoid the humoral (antibody) immune
response (eg, Legionella, Neisseria gonorrhoeae, Listeria monocytogenes, viruses, Leishmania).
response (eg, Legionella, Neisseria gonorrhoeae, Listeria monocytogenes, viruses, Leishmania).
(Choice C) Individuals usually develop serum antibodies against C difficile toxins, not spores.
(Choice E) Rapid gastrointestinal transit is rarely effective at "washing away" pathogenic
diarrhea-causing organisms as they are well-adapted to adhering to the gut mucosa in the
setting of voluminous diarrhea.
In the absence of normal intestinal microbial flora (as may be the case after a course of
antibiotics), Clostridium difficile can overgrow and produce enterotoxin (toxin A) and cytotoxin
(toxin B). Clinical disease resulting from C difficile overgrowth can range from transient
diarrhea to severe pseudomembranous colitis.
20
A 42-year-old homeless man comes to the emergency department due to painful muscle
spasms. The patient has had frequent involuntary contractions of the jaw, neck, and trunk
muscles, which are triggered by sensory stimuli. He has a history of injection drug use and has
had several injection site infections. Physical examination shows neck stiffness and decreased
opening of the jaw. Which of the following is the most likely path taken by the agent
responsible for this patient's condition?
Bite wound → peripheral nerves → CNS neurons [8%]

A.
Contaminated food → systemic circulation → presynaptic nerve terminals [4%]

B.
Infected wound → systemic circulation → brain parenchyma [8%]

C.
Nasopharyngeal exudate → systemic circulation → neurons [1%]

D.
Oral mucosa → trigeminal nerve → temporal lobe [1%]

E.
Puncture wound → motor neurons → spinal cord interneurons [75%]
F.
This patient with painful muscle spasms and neck/jaw contraction likely has tetanus, which is
caused by the spore-forming anaerobic bacterium Clostridium tetani. C tetani spores are found
in soil worldwide and are typically transmitted to humans during a puncture injury (eg, dirty
needle use, splinter). The low oxygen tension of a puncture wound allows spores to germinate
into vegetative rod-shaped bacteria that proliferate locally and produce tetanospasmin
(tetanus toxin).
Although the pathogen is noninvasive (it stays localized to the wound site), the toxin enters the
presynaptic terminals of the lower motor neurons and travels by retrograde axonal transport to
the CNS. In the spinal cord, at the level of the anterior horn cells, the toxin blocks inhibitory
interneurons, leading to spasmodic muscle contraction. Classic findings include jaw stiffness
due to masseter muscle spasm (trismus/lockjaw) and sustained contraction of the facial
muscles, producing a bizarre "smiling" appearance (risus sardonicus). Spasmodic contraction of
the back and neck can cause opisthotonos, and respiratory muscle involvement that can lead to
respiratory failure.
(Choice A) Rabies virus is transmitted via the saliva of an infected animal during a bite
wound. The virus spreads by retrograde axonal transport through peripheral nerves and enters
the spinal cord/CNS. Patients with rabies usually develop painful pharyngeal spasms,
hydrophobia, fever, and hyperactivity. However, this patient has no history of an animal bite;
he likely developed tetanus due to a puncture wound with a contaminated needle.
(Choice B) Food-borne botulism is marked by the ingestion of preformed botulism toxin with
subsequent spread through the systemic circulation. The toxin blocks cholinergic presynaptic
nerve terminals, which results in symmetric, descending weakness.
(Choice C) Bacteria (eg, Staphylococcus aureus) from a wound can spread through the
(Choice C) Bacteria (eg, Staphylococcus aureus) from a wound can spread through the
bloodstream to the brain leading to brain abscess. Symptoms vary but the most common
manifestation is unilateral headache.
(Choice D) Diphtheria is associated with the formation of a pseudomembranous pharyngeal
exudate and the elaboration of diphtheria toxin into the systemic circulation. The toxin causes
cardiac (myocarditis) and neurologic toxicity.
(Choice E) Herpes simplex virus type 1 causes orolabial lesions and is the most frequent cause
of sporadic encephalitis, which occurs when the virus spreads via the olfactory tract to the
temporal lobe (olfactory cortex). Patients usually present with confusion, fever, focal
neurologic deficits, and seizures.
Tetanus is caused by infection with toxigenic strains of the anaerobic bacterium Clostridium
tetani. Transmission typically occurs when spores are inoculated into the skin via a puncture
wound. The bacteria germinate, replicate locally, and elaborate tetanospasmin (tetanus
toxoid). The toxin spreads in a retrograde fashion through the lower motor neurons to the
spinal cord, where it blocks inhibitory interneurons and causes spasmodic muscle contraction
(eg, trismus, risus sardonicus).
21
A 5-month-old Hispanic boy is brought to the ER with complaints of poor feeding, weakness and
complete loss of extremity muscle tone. All of his vaccinations are up to date and there is no
significant past medical history. He receives formula as his sole source of nutrition with the
exception of occasional fruit juice and honey. He has also received vitamin D
supplementation. Which of the following tests is most likely to establish the diagnosis in this
patient?
Stool for bacterial toxins [83%]
A.
Blood for liver enzymes [3%]

B.
Blood for viral titers [2%]

C.
Urine for glucose and ketones [4%]

D.
Urine for amino acids [4%]

E.
This 5-month-old baby is consuming honey, a food notorious for contamination with C.
botulinum spores. In studies, more than 12% of tested honey samples contained C.
botulinum spores. Infant botulism results when a baby consumes C. botulinum spores, which
then germinate in the infant GI tract. Intracellular toxin production, bacteriolysis resulting in
toxin release, and mild systemic absorption of toxin ensue.
In infant botulism, constipation usually precedes the characteristic signs of neuromuscular
paralysis by a few days or weeks. Other symptoms include mild weakness, lethargy, and
reduced feeding. Some infants, however, show more severe symptoms such as weakened suck,
swallowing, and crying; generalized muscle weakness; and diminished gag reflex. In severe
cases, the generalized muscle weakness and loss of head control can cause the infant to appear
"floppy." (In contrast, adult botulism, which results from ingestion of preformed toxin, is almost
always very severe.)
Infant botulism can usually be diagnosed based on the patient's clinical presentation and food
consumption history. Culture and isolation of the organism and bioassay of toxins are time-
consuming procedures, but rapid in vitro procedures have been developed for the detection of
types A, B, E, and F botulinum toxin-producing organisms and their toxins. The tests are based
on ELISA methodology and polymerase chain reaction techniques.
(Choice B) Measurement of blood liver enzyme levels is a nonspecific test that can indicate
infectious liver disease such as that caused by viral hepatitis. Liver enzyme levels are typically in
the thousands in acute viral hepatitis and in the hundreds in chronic disease.
(Choice C) Serum viral titers are frequently used to monitor the effectiveness of HAART therapy
in patients with HIV. Serologies are used more commonly in the evaluation of viral hepatitis
and in patients with suspected Epstein-Barr and cytomegalovirus infections.
(Choice D) High levels of urine glucose and ketones can indicate diabetic ketoacidosis.
(Choice E) Patients with amino acids in their urine may have a disorder of renal amino acid
resorption, such as Fanconi syndrome or Hartnup disease.
Infant botulism is frequently due to honey consumption. More than 12% of honey samples
contain low numbers of C. botulinum spores. Whereas infant botulism results from
consuming C. botulinum spores, adult botulism results from consuming preformed toxin,
typically in canned food. Symptoms of infant botulism include constipation, mild weakness,
lethargy, and poor feeding.
22
A 65-year-old man comes to the physician due to right-calf pain, redness, and swelling. He is
diagnosed with cellulitis and is started on clindamycin. A few days after starting treatment, he
develops watery diarrhea and abdominal cramps. The patient is hospitalized, and complete
blood count shows leukocytosis. The toxin most likely responsible for his current condition
primarily damages which of the following components of intestinal mucosal cells?
Apical ion transport [24%]

A.
Cell membrane integrity [19%]

B.
Cytoskeleton integrity [44%]
C.
Mitochondrial energy production [1%]

D.
Ribosomal protein synthesis [10%]

E.
Clostridium difficile is part of the gut's normal microbial flora; it is present in 2%-3% of healthy
adults and in approximately 70% of healthy infants. Disease can result after administration of
antibiotics that are lethal to other commensal gut organisms, which help keep potentially
pathogenic organisms such as C difficile in check. Common antibiotics implicated in C
difficile colitis include clindamycin, fluoroquinolones, penicillins, and broad-spectrum
difficile colitis include clindamycin, fluoroquinolones, penicillins, and broad-spectrum
cephalosporins.
Pathogenic strains of C difficile produce 2 distinct toxins: toxin A (enterotoxin) and toxin B
(cytotoxin). Both seem to act synergistically in C difficile colitis pathogenesis, although toxin B
is significantly more virulent. The toxins bind specific receptors on intestinal mucosal cells and
are internalized, allowing them to exert their effects. Both toxins inactivate Rho-regulatory
proteinsinvolved in signal transduction and actin cytoskeletal structure maintenance. As a
result, the toxins cause disruption of intercellular tight junctions leading to cell
rounding/retraction as well as increased (paracellular) intestinal fluid secretion. Both toxins
have inflammatory effects (including neutrophil recruitment) and can induce
apoptosis. Although these toxins have overlapping activity, toxin A appears to be more
enterotoxic and toxin B more cytotoxic.
(Choice A) Apical ion transport is affected by the cholera toxin (main exotoxin of Vibrio
cholerae). The A subunit of this AB exotoxin activates adenylate cyclase through a G-protein
mechanism, which leads to decreased salt reabsorption and increased transport of sodium and
chloride out of the gut mucosal cell. As a result, a large amount of water is lost into the gut
lumen, leading to watery diarrhea.
(Choice B) Loss of cell membrane integrity is characteristic of alpha toxin lecithinase (one of
many exotoxins released by Clostridium perfringens). C perfringens can cause transient watery
diarrhea. However, it is most frequently associated with clostridial myonecrosis (gas gangrene),
a rapidly progressive form of fasciitis associated with penetrating injury by soil-contaminated
objects.
(Choice D) Mitochondria are the primary source of ATP in human cells. Cyanide and nucleoside
reverse transcriptase inhibitors are examples of drugs associated with mitochondrial toxicity.
(Choice E) Ribosomal protein synthesis is inhibited by shiga and shiga-like toxins. Shiga toxin is
the main exotoxin released by Shigella species; shiga-like toxin (verotoxin) is produced by
enterohemorrhagic Escherichia coli (eg, O157:H7). These organisms are not part of normal gut
flora; transmission occurs via the fecal-oral route.
Clostridium difficile toxins A and B exert their effects by disrupting the actin cytoskeletal
structure and intracellular signaling. Although the toxins have overlapping effects, toxin A
causes relatively more intestinal inflammation and fluid secretion, and toxin B is more
cytotoxic.
23
A 62-year-old man comes to the physician because of recent weight loss, cough, and occasional
hemoptysis. His past medical history is significant for poorly controlled diabetes mellitus and
chronic obstructive pulmonary disease treated with bronchodilators and oral
corticosteroids. Chest x-ray shows pulmonary infiltrates and an area of cavitation in the right
upper lobe. Sputum microscopy shows acid-fast bacilli. Which of the following is the most
accurate statement concerning this patient's pulmonary infection?
First exposure to the bacilli occurred recently [3%]

A.
Healing of the lung lesion would result in Ghon complex formation [8%]
B.
It originated from reactivation of an old infection [84%]
C.
It was facilitated by low levels of protective antibodies [2%]

D.
Negative tuberculin skin test would signify strong cell-mediated immunity [0%]
E.
This patient's symptoms (cough, hemoptysis, weight loss), acid-fast bacilli on sputum culture,
and upper lobe cavitary lesion are suggestive of secondary (reactivation) tuberculosis. His
advanced age, multiple comorbidities, and partial immune suppression secondary to chronic
oral corticosteroid use also place him at risk for reactivation disease.
Primary tuberculosis infection occurs following inhalation of aerosolized Mycobacterium
tuberculosis. The organisms are deposited in the lower lungs and phagocytosed by alveolar
macrophages, where they proliferate until the macrophages are activated by T H1
macrophages, where they proliferate until the macrophages are activated by T H1
lymphocytes. The infection can be subsequently eliminated if the area of involvement is small
enough. However, larger regions of caseating necrosis become walled off, allowing M
tuberculosis to survive in a dormant state without causing disease or symptoms. Later in life
(usually following immunosuppression by drugs or HIV) the bacteria can reactivateand establish
infection in the upper lungs (particularly the apex). d The organisms multiply in the apices,
causing caseous and liquefactive necrosis and extensive cavitary disease. Erosion into the
pulmonary vessels can result in severe hemoptysis. Hematogenous dissemination may also
occur, causing miliary or extrapulmonary (eg, Potts disease, tuberculous meningitis)
tuberculosis.
(Choice A) Primary tuberculosis infection often begins as a focal lesion in the mid-to-lower
lungs (Ghon focus). M tuberculosis then spreads lymphatically to the hilar lymph nodes,
forming a Ghon complex. The organisms can remain dormant in a walled-off Ghon complex for
many years before reactivating. Alternatively, the lesion may heal, forming a benign, calcified
Ranke complex that is not associated with reactivation tuberculosis.
(Choice B) A Ghon complex forms during primary tuberculosis infection and consists of a Ghon
focus and hilar lymphadenopathy. This patient's upper lung involvement and cavitary lesion are
more characteristic of secondary (reactivation) tuberculosis. Healing of this lesion would result
in a persistent cavity that may become secondarily infected with Aspergillus flavus and form
fungus balls.
(Choice D) M tuberculosis is a facultative intracellular bacterium that can survive and multiply
within macrophages; as a result, circulating antibodies cannot bind it to promote phagocytosis
or complement-mediated killing. Therefore, humoral immunity plays no role in the control
of M tuberculosis.
(Choice E) A negative skin tuberculin test after M tuberculosis exposure suggests anergy
against tuberculosis antigens and a weak cell-mediated immune response. This can occur in the
setting of HIV, sarcoidosis, and other illnesses.
Primary tuberculosis causes the formation of Ghon foci in the lower lungs. Secondary
(reactivation) tuberculosis occurs in patients with prior tuberculosis infection that never cleared
completely. Reactivation tuberculosis occurs most often in immunosuppressed patients and is
characterized by apical cavitary lesions and hemoptysis.
24
A 58-year-old asymptomatic woman comes to the office for a health checkup prior to starting
volunteer work at a hospital. She has a history of hypothyroidism and takes levothyroxine. She
does not use tobacco, alcohol, or illicit drugs. Her examination findings are
unremarkable. During a laboratory test, her white blood cells are incubated with mycobacterial
antigens. Compared to the control, a large amount of interferon-gamma is detected in her
blood sample. Which of the following cell types is most directly responsible for this finding?
B lymphocytes [3%]
A.
Basophils [0%]
B.
Eosinophils [0%]
C.
Monocytes [17%]
D.
Neutrophils [4%]
E.
T lymphocytes [73%]
F.
Interferon-gamma (IFN-γ) activates macrophages, increases major histocompatibility complex
expression, and promotes T helper 1 lymphocyte (Th1) differentiation. It is produced primarily
by activated T lymphocytes and natural killer cells and is critical in immunity against viral and
intracellular bacterial infections. IFN-γ release assays (IGRAs) test for latent tuberculosis
infection (LTBI) by measuring the response of T lymphocytes when exposed to antigens unique
to Mycobacterium tuberculosis. Similar to tuberculin skin tests (eg, purified protein derivative),
IGRAs measure cell-mediated immunity.
IGRAs have comparable sensitivity and specificity to tuberculin skin tests, but advantages
include their lack of cross-reactivity to the Bacille Calmette-Guérin (BCG) vaccine and that a
follow-up visit is not required. Neither skin tests nor IGRAs can be used to distinguish active
tuberculosis from LTBI.
Exhibit Display
(Choice A) B lymphocytes are the main cell type involved in the humoral immune system and
the production of circulating antibodies.
(Choices B and D) Basophils and antigen-presenting cells such as monocyte-derived
macrophages interact with T cells to control the immune response but are not directly
responsible for IFN-γ release.
(Choices C and E) Eosinophils help eradicate parasitic infections (eg, helminths), whereas
neutrophils are involved in the phagocytosis of bacteria and other pathogens.
Interferon-gamma (IFN-γ) release assays test for latent tuberculosis infection by measuring the
amount of IFN-γ released by T lymphocytes when exposed to antigens unique
to Mycobacterium tuberculosis.
25
Bacteria isolated from the lung tissue of a 32-year-old Caucasian male fail to decolorize with
hydrochloric acid and alcohol after staining carbolfuchsin. Which of the following cell wall
components is most likely responsible for this staining phenomenon?
N-acetylmuramic acid [7%]

A.
Teichoic acid [14%]

B.
Lipopolysaccharide [12%]
C.
Mycolic acid [60%]
D.
Ergosterol [4%]
E.
The procedure described above is the acid-fast stain, which is used in the detection of a select
few pathogenic organisms (eg, Mycobacterium and some Nocardia species). Although it is less
sensitive than culture, the acid-fast stained smear allows for immediate microscopic evaluation.
In the acid-fast stain for mycobacteria, the smear is first treated with an aniline dye (eg,
carbolfuchsin). The dye (red color) penetrates the bacterial cell wall, where it binds with
mycolic acids. The slide is then treated with hydrochloric acid and alcohol. This acid alcohol
dissolves the outer cell membranes of nontuberculous bacteria, but the presence of mycolic
acids prevents decolorization of mycobacteria. A counterstain (eg, methylene blue) is then
applied and taken up by decolorized bacteria. As a result, the carbolfuchsin acid-fast stain
produces red mycobacteria (initial stain) and blue non-acid fast bacteria.
The cell membrane and cell wall of mycobacteria are most similar to those in Gram-positive
organisms, causing mycobacteria to appear weakly positive on Gram stain. However, the
mycobacterial cell wall differs from that of the typical Gram-positive organism in that they are
encapsulated with mycolic acid, a waxy, long-chain fatty acid that is covalently bound to the
sugars within the cell wall. Another organism that will also stain positive with the acid-fast
technique is Nocardia. Nocardia is a Gram-positive rod that contains mycolic acid in its cell
wall. Because Nocardia possesses less mycolic acid than do mycobacteria, Nocardia is more
weakly acid fast.
(Choice A) N-acetylmuramic acid and N-acetylglucosamine are the saccharides that combine
with an amino acid chain to form the peptidoglycan layer in both Gram-positive and Gram-
negative cell walls.
(Choice B) Teichoic acid is a molecule linked to the peptidoglycan cell wall of Gram-positive
bacteria (but not Gram-negative bacteria). Teichoic acid serves as an antigenic determinant for
bacteria (but not Gram-negative bacteria). Teichoic acid serves as an antigenic determinant for
organism identification in the laboratory and an antigenic target for the human immune
system.
(Choice C) Lipopolysaccharide (LPS) is a component of the outer cell envelope of Gram-negative
bacteria.
(Choice E) Unique to fungi, ergosterol is the sterol component of fungal cell membranes. This
molecule is not found in human cell membranes, as human cells have cholesterol in their cell
membranes instead.
The acid-fast stain identifies organisms that have mycolic acid present in their cell walls,
including Mycobacteriumand some Nocardia species. Acid-fast staining is carried out by
applying an aniline dye (eg, carbolfuchsin) to a smear and then decolorizing with acid alcohol to
reveal whether the organisms present are "acid fast."

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1

Bacterial exotoxin production in the gut [9%]

Bacterial invasion of the gut mucosa [2%]

Ingestion of preformed enterotoxin [85%]

Microbial attachment to the intestinal surface [1%]

Systemic absorption of luminal endotoxin [1%]

Enterotoxigenic Staphylococcus aureus is a leading cause of foodborne illness. This pathogen

Heat-stable exotoxin [16%]

Fimbrial antigen [8%]

Flagellar antigen [1%]

Activation of toll-like receptors by bacterial components [24%]

Binding of T-cell receptors by bacterial secretory products [55%]

Bridging of cell-bound IgE by multivalent antigens [3%]

Phagocytosis of bacteria in the blood by neutrophils [8%]

Presentation of processed antigens by dendritic cells [6%]

Coagulase positive [15%]

Novobiocin resistant [72%]

DNase positive [2%]

Yellow pigment producer [4%]

Alveolar hyaline membrane formation [3%]

Antiphagocytic microbial capsule [72%]

Endotoxin-induced cell necrosis [4%]

Intracytoplasmic location of the organism [11%]

Streptococcus pneumoniae is a gram-positive, lancet-shaped organism that grows in pairs

Microbial skin invasion [2%]

Endotoxin-mediated inflammatory response [12%]

Exotoxin-mediated skin damage [70%]

Mast cell degranulation [2%]

Cell-mediated hypersensitivity [11%]

Staphylococcal Scalded Skin Syndrome (SSSS) is caused by certain strains of Staphylococcus

Excrete antibiotics [5%]

Protect from osmotic lysis [7%]

Provide mechanical cell support [31%]

Resist phagocytosis [46%]

Transport nutrients into the cell [8%]

Penicillin at 30 weeks gestation [27%]

Maternal vaccination [12%]

Intrapartum ampicillin [50%]

Postnatal immunoglobulin [6%]

Breast feeding restriction [2%]

The finding of Gram-positive cocci in chains indicates Streptococcus as Staphylococci classically

Alpha hemolysis [3%]

Mannitol fermentation [2%]

Negative catalase test [6%]

Negative coagulase test [78%]

Novobiocin resistance [8%]

Yellow pigment production [1%]

Staphylococcus epidermidis is a low-virulence skin commensal that rarely causes infection in

Avoidance of exposure to bird droppings [3%]

Immediate chemoprophylaxis after exposure [3%]

Immunization with inactivated microbial agent [12%]

Periodic culture and disinfection of water supply [2%]

Vaccination with bacterial polysaccharide [79%]

Inhibition of host protein synthesis [2%]

Motility within host tissue [1%]

Prevention of phagosome-lysosome fusion [5%]

Resistance to phagocytosis [86%]

Survival in extreme environments [3%]

Candida albicans [1%]

Eikenella corrodens [0%]

Klebsiella pneumoniae [1%]

Nocardia asteroides [0%]

Staphylococcus aureus [88%]