Textbook of Diagnostic Microbiology

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Chapter 10: Immunodiagnosis of Infectious Diseases
Mahon: Textbook of Diagnostic Microbiology, 6th Edition

MULTIPLE CHOICE

1. When a person is exposed to an antigen for a second time, what type of response is
mounted?
a. Anamnestic
b. Tertiary
c. Full blown
d. Allergic
ANS: A
A subsequent exposure to the same antigen elicits a secondary or anamnestic response,
characterized by a rapid increase in IgG antibody associated with higher levels, a
prolonged elevation, and a more gradual decline.

OBJ: Level 1: Recall

2. John goes to his physician complaining of a high fever (38.2° C [102° F]), muscle aches,
cough, and a headache. These symptoms came on suddenly, and his physician thinks John
may have the flu. What kind of antibody is his body producing against the virus?
a. IgG
b. IgM
c. IgE
d. IgD
ANS: B
A positive result for IgM antibody is considered indicative of a primary, current, or very
recent infection. John just became ill, so this is a primary response to a virus. Therefore
the antibody produced is IgM.

OBJ: Level 3: Synthesis

3. Mary went out to eat shellfish last week and is now beginning to feel lethargic. Her urine
is tea-colored, and she generally feels bad all over. She recognizes these symptoms and
thinks she may have hepatitis A because she got hepatitis last year when she vacationed at
the beach. If a physician were to perform a test for hepatitis A antibodies, what class of
antibodies would the physician find?
a. IgM
b. IgE
c. IgG
d. IgD
ANS: C
The presence of IgG antibodies alone suggests a previous infection or exposure to an
infectious agent.

OBJ: Level 3: Synthesis

4. If a baby were exposed to hepatitis A in utero, what type of antibodies would be
produced?
a. IgD
b. IgE
c. IgG
d. IgM
ANS: D
The presence of significant levels of IgM antibodies (with or without IgG) in a newborn
suggests in utero infection (IgM can be synthesized by the fetus and cannot cross the
placenta), whereas IgG antibody only in the newborn is passive material transfer of
antibodies.

OBJ: Level 2: Interpretation

5. What is one of the most popular methods for physical removal of IgG?
a. Miniature ion-exchange chromatography columns
b. Thin-layer chromatography
c. High-performance liquid chromatography (HPLC)
d. Mass spectroscopy
ANS: A
One of the most popular methods for physical removal of IgG uses miniature
ion-exchange chromatography columns to trap IgM while allowing IgG to be washed
through with a buffer solution. The IgM antibody is then collected by elution from the
column with a lower pH buffer.

OBJ: Level 1: Recall

6. How can one determine if a person has had a previous illness with an organism?
a. Perform acute and convalescent IgM levels.
b. Perform acute and convalescent IgG levels.
c. Perform an IgM level 1 week after the symptoms start.
d. Perform an IgG level 1 week after the symptoms start.
ANS: B
Unless a serologic test is designed to measure IgM-specific antibody for diagnosing a
current infection or is being used to determine previous infections or immunization
(immune status) by testing the IgG level in a single serum specimen, serodiagnosis of an
infectious disease requires measurement of total antibody concentration in both
acute-phase and convalescent-phase serum specimens.

OBJ: Level 2: Interpretation

7. A significant rise in IgG detected during the convalescent phase is diagnostic for infection
and is called
a. serologic adaptation.
b. convalescence.
c. seroconversion.
d. acute phase reactant.
ANS: C
 A significant rise in IgG detected during the convalescent (recovery phase), usually 2
weeks after onset of illness, is diagnostic for infection and is referred to as seroconversion.
Although seroconversion usually occurs within 2 to 3 weeks after onset of illness, it may
be delayed in certain patients or types of infection.

OBJ: Level 1: Recall

8. A monoclonal antibody is
a. an antibody that is derived from one cell, exposed to many epitopes.
b. an antibody that is derived from many cells, exposed to one epitope.
c. an antibody that is derived from one cell and exposed to no epitopes.
d. an antibody that is derived from one cell initially, which has been exposed to one
epitope.
ANS: D
This antibody is derived from one cell initially, which has been exposed to one epitope.
This cell then divides and produces an antibody specific to this one epitope. Monoclonal
antibodies are rarely found in nature and are usually associated with some type of
abnormal immune disease process.

OBJ: Level 1: Recall

9. Avidity means the antibodies have

a. strong binding kinetics to specific antigens.
b. weak binding kinetics to specific antigens.
c. strong binding kinetics to specific antibodies.
d. weak binding kinetics to specific antibodies.
ANS: A
These antibodies have strong binding kinetics to specific antigens and have the ability to
discriminate between closely related antigenic determinants.

OBJ: Level 1: Recall

10. When the antigen-binding sites on the antibody molecule react with specific epitopes and
not with other antigens containing different epitopes, this is antibody molecule is
displaying
a. high sensitivity.
b. high specificity.
c. low specificity.
d. low sensitivity.
ANS: B
Most antigen-antibody reactions show high specificity; that is, the antigen-binding sites on
the antibody molecule react with specific epitopes and not with other antigens containing
different epitopes.

OBJ: Level 1: Recall

11. Heterophile antibodies are

a. antibodies produced in response to one antigen.
b. antibodies that must be cleared through the thymus before going into circulation.
 c. antibodies produced in response to one molecule that also react against an antigen
from another species.
d. antibodies produced by T cells.
ANS: C
Antibodies produced in response to one molecule that also react against an antigen from an
unrelated source are called heterophile antibodies. Because of antibody cross-reactivity, it
is often best to perform a battery of serologic tests using organisms known to show
cross-reactivity.

OBJ: Level 1: Recall

12. A false-negative serologic test is defined as a

a. positive result for someone who is not infected.
b. negative result for someone who does not have the disease.
c. positive result for someone who does have the disease.
d. negative result for a patient who really is infected.
ANS: D
A false-negative serologic test is defined as a negative result for a patient who really is
infected.

OBJ: Level 1: Recall

13. A false-negative test may be caused by all the following immune system-mediated
reasons, except
a. allergic reaction.
b. no immune response.
c. immunodeficiency disease.
d. immunosuppression.
ANS: A
A false-negative serologic test result may occur because a person does not have an intact
immune system and cannot mount an immune response. This might be the case in an
individual with a congenital or acquired immunodeficiency disease or in a patient
receiving either immunosuppressive therapy after organ transplantation or cancer
chemotherapy. In addition, neonates may not always respond to an infectious agent
because their immune systems are immature.

OBJ: Level 2: Interpretation

14. What can cause a false-positive IgM serologic test?

a. The presence of IgG antibodies
b. The presence of rheumatoid factors
c. The presence of Rh factor
d. The presence of cytomegalovirus (CMV) antibodies
ANS: B
False-positive IgM antibody assays may also occur. These are due to the presence of
rheumatoid factor activity in the serum. Rheumatoid factor is IgM antibody, produced in
some individuals, that binds to the Fc region of the individual’s own IgG. IgM rheumatoid
factor cannot be readily differentiated from organism-specific IgM in some serologic tests.
 OBJ: Level 1: Recall

15. Antibodies for many antigens can be passively acquired in

a. vaccinations.
b. flu shots.
c. intravenous immunoglobulin therapy.
d. All of the above
ANS: C
Finally, individuals receiving intravenous immunoglobulin, a product prepared by pooling
large quantities of plasma from multiple volunteer donors, may show a specific antibody
to a variety of infectious agents because of passive transfer, not active infection.

OBJ: Level 1: Recall

16. Serologic tests can help epidemiologists

a. determine if people in a particular area are immune to an infectious agent.
b. identify people that need to get immunizations.
c. identify children that need to get immunizations.
d. determine how widespread an infectious agent is in a given area.
ANS: D
Serologic tests for a specific infectious agent or a battery of agents may be performed to
determine the percentage of individuals previously exposed or infected with the agent (s)
in a geographic area. This information provides epidemiologists and public health officials
with information about how widespread an infectious agent is in a given area.

OBJ: Level 2: Interpretation

17. What tests are performed on newborns to detect congenital infections?

a. TORCH
b. TWAR
c. CMV
d. HIV
ANS: A
The agents most commonly tested for are the TORCH agents: Toxoplasma gondii, rubella
virus, CMA and herpes simplex, and the Treponema pallidum subspecies pallidum. IgM
antibody detection on neonatal serum is the method of choice for serologic diagnosis of
congenital infection by one of the TORCH agents.

OBJ: Level 1: Recall

18. What is the principle of direct antigen testing?

a. A clinical specimen is mixed with an antigen, then a labeled antibody is added. If
the antigen is present, a complex will form.
b. It is a process by which microbial antigens are identified in patient specimens by
combining specifically with antibody molecules to form stable complexes.
c. A fluorescent antigen is added to a specimen, then an antibody to form sandwich
complexes.
d. Labeled antigen is added to a specimen, and the specimen is read for fluorescence.
 ANS: B
Direct microbial antigen detection is the process by which microbial antigens, such as
capsular polysaccharide or cell wall components, are identified in specimens obtained
from an infected host. These antigens can be recognized by and can combine specifically
with antibody molecules to form stable complexes.

OBJ: Level 1: Recall

19. In precipitation assays, what is the precipitate made out of?

a. Complement and protein complex
b. Antibody and protein complex
c. Antigen and antibody complex
d. Antigen and protein complex
ANS: C
The precipitation reaction is found in assays involving the diffusion of soluble antigen and
antibody. At a critical point, when the concentrations are optimal, a visible precipitate
forms, which is composed of an insoluble complex of antigens and antibodies.

OBJ: Level 1: Recall

20. What is the principle of the flocculation test?

a. The antigen is incorporated into the agar and the test wells hold the antibody. The
antibody and antigen combine at a specific concentration and produce a zone of
equivalence.
b. Antibodies are mixed with a labeled antigen, and a sandwich reaction occurs.
c. Antibodies and antigens combine then precipitate out of a solution to the bottom of
the tube.
d. The antigen-antibody reaction forms a macroscopically visible clump that remains
in solution.
ANS: D
Flocculation tests are a variation of precipitation tests that also have some properties of
agglutination assays. In these tests, because of the chemical nature of the antigen (not a
truly soluble antigen), the antigen-antibody reaction forms a macroscopically or
microscopically visible clump or precipitate of fine particles that remain in suspension.

OBJ: Level 1: Recall

21. Indirect agglutination is also referred to as

a. passive agglutination.
b. incomplete agglutination.
c. active agglutination.
d. flocculation.
ANS: A
Indirect agglutination is also referred to as passive agglutination. The antigen or antibody
is bound to a particulate carrier before forming an immune complex.

OBJ: Level 1: Recall

22. All of the following controls must accompany the patient specimens in a latex
agglutination test for antigen detection, except
a. positive antigen control.
b. negative antigen control.
c. latex suspension control.
d. positive antibody control.
ANS: D
Some important controls must accompany the patient specimens. These controls include a
positive antigen control (a solution containing the known antigen of interest), a negative
antigen control (a solution not containing the antigen), and a control of latex suspension to
detect the presence of nonspecific agglutination reactions.

OBJ: Level 2: Interpretation

23. Prozone occurs

a. when the relative concentration of an antibody exceeds the concentration of an
antigen.
b. when the relative concentration of an antigen exceeds the concentration of an
antigen.
c. when there are interfering substances in the specimen.
d. in the equivalence zone.
ANS: A
Prozone occurs when the relative concentration of an antibody exceeds the concentration
of an antigen. In this situation, each antigen combines with one or two antibody molecules,
and cross-linking between antigen and antibody does not occur.

OBJ: Level 1: Recall

24. The advantages of latex agglutination include all the following, except
a. availability of good quality reagents in complete kit form.
b. good sensitivity.
c. ease of performance.
d. cost of reagents.
ANS: D
The advantages of latex agglutination tests are the availability of good quality reagents in
complete kit form, good sensitivity, relative rapidity, and ease of performance.
Disadvantages include subjectivity in reading endpoints and nonspecific reactions
resulting from interfering substances in clinical samples. LA tests are relatively
inexpensive when compared to other methods.

OBJ: Level 1: Recall

25. What test principle uses microbial antigens that are attached to erythrocytes after chemical
treatment of the cells that promotes cross-linking of the antigens?
a. Indirect hemagglutination (IHA)
b. Enzyme immunoassay (EIA)
c. Complement fixation (CF)
d. Latex agglutination (LA)
 ANS: A
In passive or indirect hemagglutination, microbial antigens are attached to erythrocytes
after chemical treatment of the cells with tannic acid, chromic chloride, glutaraldehyde, or
another substance that promotes cross-linking of the antigens. The sensitized cells can then
be reacted with patient’s serum to detect an agglutinating antibody.

OBJ: Level 1: Recall

26. A direct fluorescent antibody (DFA) test involves

a. an antigen-specific labeled antibody.
b. an antibody-specific labeled antigen.
c. a bioluminescent label.
d. None of the above
ANS: A
Detection techniques may be direct or indirect. In the DFA test, the clinical specimen
containing the antigen of interest is fixed onto a glass slide with formalin, methanol,
ethanol, or acetone. The antigen-specific labeled antibody is applied to the fixed specimen,
incubated, washed, and examined with a fluorescent microscope. If the antigen was
present in the clinical specimen, the labeled antibody will bind to the antigen and
fluorescence will be seen.

OBJ: Level 1: Recall

27. Enzyme immunoassay (EIA) differs from immunofluorescent tests by

a. using a different fluorescent label.
b. using enzymes and a chromogenic substrate.
c. being valid for direct testing only.
d. All of the above
ANS: B
EIA provides an alternative to immunofluorescent assays for detecting antigens and
antibodies in clinical samples. Instead of labeling an antibody with a fluorochrome, EIA
depends on the fact that enzyme molecules can be conjugated to specific antibodies in
such a way that both enzymatic and antigen-binding activities are preserved.

OBJ: Level 1: Recall

28. What is the advantage of using an indirect sandwich assay for EIA?
a. One enzyme conjugated antiimmune antibody can be used for several tests.
b. It is much more specific than direct sandwich EIA.
c. It is much more sensitive than direct sandwich EIA.
d. The lower detection limit is superior to any other EIA test.
ANS: A
The advantage of the indirect sandwich immunoassay is the need for only one enzyme
conjugated antiimmunoglobulin antibody (third antibody) that can be used in different
assays to detect a variety of antigens.

OBJ: Level 1: Recall

29. What test has its results reported as the relative amount of a signal generated by the
patient’s serum when compared with that of a known weakly positive serum?
a. Enzyme immunoassay (EIA)
b. Enzyme-linked immunosorbent assay (ELISA)
c. Radioimmunoassay (RIA)
d. Solid phase immunobead assay (SPIA)
ANS: B
Many laboratories are using some form of ELISA testing for antibody detection. In this
test, results are reported not as antibody titer but as they relate to the relative amount of
signal generated by the patient’s serum when compared with that of a known weakly
positive serum. Results are usually reported either as relative units with a numerical
reference range (units/mL) or as a ratio of results in the sample to the low positive control.

OBJ: Level 1: Recall

30. What are the benefits of using membranes to perform enzyme immunoassay (EIA)
reactions?
a. They improve specificity and signal strength.
b. They enhance speed and signal strength.
c. They enhance speed and sensitivity.
d. They improve specificity and sensitivity.
ANS: C
The flow-through and large surface area characteristics of nitrocellulose, nylon, or other
membranes have been demonstrated to enhance the speed and sensitivity of EIA reactions.
The improvements associated with membrane-bound EIAs are largely the result of
immobilizing antibody onto the surface of porous membranes.

OBJ: Level 1: Recall

31. What is used as the indicator in a complement fixation (CF) test?

a. Latex particles
b. Horse red blood cells
c. Rabbit red blood cells
d. Sheep red blood cells
ANS: D
The CF test is performed as a two-step procedure. The patient’s serum is serially diluted in
test tubes, and each dilution is mixed with a known amount of antigen. A fixed amount of
complement is then added to each tube, and the mixture is incubated. Next, the sheep
erythrocytes and rabbit antibody are added to each tube, and the tubes are incubated again.

OBJ: Level 1: Recall

32. What is one of the biggest uses for Western blot tests in the laboratory today?
a. Confirming antibodies to HIV
b. Confirming antibodies to cytomegalovirus (CMV)
c. Confirming antibodies to rubella
d. DNA sequencing from herpes
ANS: A
 Western blotting has gained importance and is extensively used to confirm antibodies to
HIV type 1 in patients whose sera have been repeatedly reactive in enzyme immunoassay
(EIA) tests.

OBJ: Level 1: Recall

33. What is the difference between dot blots and Western blots? In dot blot testing
a. proteins are blotted to specific areas.
b. proteins are purified and directly blotted to specific locations on the solid surface.
c. DNA is purified and directly blotted to specific locations on the solid surface.
d. RNA is purified and directly blotted to specific locations on the solid surface.
ANS: B
Immunoblots, or dot blots, are similar to Western blots, except the protein antigens are not
electrophoretically separated and transferred to a solid surface. Instead, the proteins are
purified and directly applied (blotted) to specific locations on the solid surface.

OBJ: Level 1: Recall

34. Confirmatory tests for syphilis include all the following, except
a. FTA-ABS.
b. TP-PA.
c. RPR.
d. MHA-TP.
ANS: C
Examples of confirmatory tests for syphilis include the fluorescent treponema antibody
absorbance (FTA-ABS) test and the Treponema pallidum particle agglutination (TP-PA)
test, which has generally replaced the microhemagglutination assay for the Treponema
pallidum (MHA-TP) test. Nontreponemal antigen tests are technically easier and more
rapid to perform; therefore they are the tests of choice for syphilis screening. The most
commonly used nontreponemal tests today are the Venereal Disease Research Laboratory
(VDRL) and the rapid plasma reagin (RPR) tests.

OBJ: Level 1: Recall

35. What is ASO used for?

a. To demonstrate serologic response to streptococcal antigen
b. To determine if a strep has been lysogenized
c. To determine if a strep produces a hemolysin
d. To demonstrate serologic response to Streptococcus pyogenes
ANS: D
The antistreptolysin-O, or ASO, antibody test is commonly used to demonstrate serologic
response to S. pyogenes.

OBJ: Level 1: Recall

36. All of the following are congenital defects produced by rubella, except
a. deafness.
b. blindness.
c. cataracts.
 d. congenital heart disease.
ANS: B
Rubella is normally insignificant except in pregnant women. This disease may cause a
miscarriage, or it may cause congenital heart disease, cataracts, deafness, and brain
damage in the unborn fetus.

OBJ: Level 1: Recall

37. What test is used to diagnose an Epstein-Barr virus (EBV) infection?

a. ASO
b. EBV antibody
c. Heterophile antibody
d. Cold agglutinin
ANS: C
The heterophile antibody titer is one of the tests used to diagnose EBV infection, the
causative agent of infectious mononucleosis. Recall that heterophile antibody refers to an
antibody with an affinity to an antigen from more than one group or species.

OBJ: Level 1: Recall

38. What patients are highly susceptible to cytomegalovirus (CMV) infections?

a. Immunosuppressed
b. Immunocompetent
c. Males
d. Females
ANS: A
Patients who are immunosuppressed are highly susceptible to CMV infection. Acquired
immunodeficiency syndrome (AIDS) patients acquiring an acute infection with CMV may
have eye damage and blindness as well as cerebral damage.

OBJ: Level 1: Recall

39. What is the earliest serologic marker detected in hepatitis B?

a. HAV
b. HBsAg
c. HBcAg
d. HBeAg
ANS: B
One of the earliest markers detected in infections is the hepatitis B surface antigen
(HBsAg).

OBJ: Level 1: Recall

40. All of the following are antigens present in a hepatitis B infection, except
a. HBsAg.
b. HBcAg.
c. HBeAg.
d. VCNA.
 ANS: D
VCNA is from Epstein-Barr virus. Additional antigen assays include detection of hepatitis
B core antigen (HBcAg) and hepatitis B early antigen (HBeAg).

OBJ: Level 1: Recall

41. All of the following are hepatitis antibodies, except

a. EBNA.
b. HBsAg.
c. HBcAg.
d. HBeAg.
ANS: A
EBNA is from the Epstein-Barr virus. The laboratory can also test for antibodies to the
various antigens: anti-HBs antibody, anti-HBc antibody, and anti-HBe antibody.

OBJ: Level 1: Recall

42. Which test is a confirmatory test of enzyme-linked immunosorbent assay (ELISA) HIV?
a. Enzyme immunoassay (EIA)
b. Northern blot
c. Southern blot
d. Western blot
ANS: D
The detection of antihuman HIV antibodies has generally used two tests: ELISA for
screening and the Western blot for confirmation. The Western blot test is highly sensitive
and specific and remains the standard confirmatory test for HIV infection.

OBJ: Level 1: Recall

43. What is one of the most widely used applications of the direct antigen test?
a. HIV in saliva
b. Group A strep in throat swabs
c. Epstein-Barr virus (EBV) in urine
d. Cytomegalovirus (CMV) in hair follicles
ANS: B
One of the most widely used applications of direct antigen tests, popularized in the 1980s,
is for the detection of group A strep in throat swab specimens for the diagnosis of
streptococcal pharyngitis.

OBJ: Level 1: Recall

44. Which organism can cause hospitalization in young children and is detected using
fluorescent antibodies?
a. Haemophilus
b. Klebsiella
c. Streptococcus
d. Respiratory syncytial virus (RSV)
ANS: D
Of particular importance is the direct detection of RSV by fluorescent antibody or
membrane-bound enzyme immunoassay (EIA) in nasopharyngeal samples. Rapid direct
detection is important because RSV causes serious lower respiratory disease (bronchiolitis
and pneumonia) in young children, often requiring hospitalization.

OBJ: Level 2: Interpretation