i

.NORMALFLORAOFTHEHUMANBODY

Mi
croor
gani
smst
hatar
ecommonl
yfoundonori
nbodysi
tesofheal
thyper
sons
ar
eter
med“
nor
malf
lor
a”. Thet
erm nor
malf
lor
aimpl
i
est
hatt
hesemi
crobesar
e
har
mlessandf
ort
hemostpar
ttheydonotcausedi
seaseandar
eev
enbenef
ici
al.The
mi
croor
gani
smsnor
mal
l
yassoci
atedwi
thapar
ti
cul
art
issueorst
ruct
uresar
ecal
l
edt
he
“
micr
obi
ota”or“
indi
genousmi
crobi
alpopul
ati
on”or“
micr
obi
alf
lor
a”.
Themi
croor
gani
smst
hatcol
oni
zeanar
eaf
ormont
hsory
ear
satat
imear
e
t
ermed‘
resi
dentf
lor
a’.Thi
sisi
ncont
rastt
otr
ansi
entf
lor
as,
whi
char
epr
esentatasi
te
t
empor
ari
l
y.Or
gani
smst
hatconst
it
utet
henor
malf
lor
acanbecl
assi
fi
edaspar
asi
tes,
sy
mbi
ont
sorcommensal
s.
Nor
malFl
oraatDi
ff
erentBodySi
tes:
The human hosti
s col
oni
zed by appr
oxi
mat
ely 100 di
ff
erentspeci
es of
mi
croor
gani
sms. Bact
eri
amakeupmostoft
henor
malf
lor
aoft
hehumanbody
al
thoughv
ari
ousf
ungi(
manyt
ypesofy
east
)andpr
otozoamayal
soi
nhabi
tthebody
andsomev
irusesar
eal
sopr
esent
.
Thef
oll
owi
ngsect
ionsdescr
ibet
hedi
str
ibut
ionandoccur
renceoft
hebact
eri
a,
f
ungiandpr
otozoat
hatcompr
iset
henor
malf
lor
aofdi
ff
erentr
egi
onsoft
hehuman
body
,begi
nni
ngwi
tht
heext
ernal
sur
face.
Nor
malFl
oraoft
heSki
n:
The ski
n cont
ains a wi
de v
ari
ety ofmi
croor
gani
sms. Commensalmi
cro-
or
gani
smsl
i
vingonori
ntheski
ncanbeei
therr
esi
dentort
ransi
entmi
crobi
ota.The
anot
amyandphy
siol
ogyoft
heski
nvar
yfr
om onepar
toft
hebodyt
oanot
her
.Theski
n
i
scomposedoft
heepi
der
mis,der
misl
ayer
. Epi
der
misl
ayeri
sout
ersur
facel
ayer
whi
ch consi
stsdead,anucl
eat
ed cel
l
sand i
tisnota f
avour
abl
eenv
ironmentf
or
col
oni
zat
ionbymi
croor
gani
sms;whi
chi
snor
mal
l
yimper
meabl
etobact
eri
a,howev
er
cut
sorbur
nscanal
l
owbact
eri
atopenet
rat
e.Beneat
htheepi
der
misl
ayer
,der
misl
ayer
i
spr
esent
.(I
tisaconnect
ivet
issuel
ayer
).
Thef
lor
aofski
ndependont
hear
eaoft
hebody
,cl
othi
ng,env
ironmentand
per
sonal
hygi
eneet
candsev
eral
fact
orssuchasDr
yness,
pH,
sweatet
car
eresponsi
ble
f
ordi
scour
agi
ngski
ncol
oni
zat
ion. Themi
crobi
otaofski
nconsi
stsoft
hegener
a

1
st
aphy
lococci
,st
rept
ococci
,di
pht
her
oids,
E.col
iaswel
last
hef
ungi
pit
yrospor
um ov
ale,
P.or
bicul
are,Candi
da al
bicans and Cr
ypt
ococcus. Some der
mat
ophy
ticf
ungi
(
Micr
ospor
um spp)maycol
oni
zet
heski
nandpr
oduceat
hlet
e’sf
oodandr
ingwor
m.
Thef
lor
aofski
nincl
udesCor
ynebact
eri
a,St
aphy
lococcusepi
der
midi
s,St
aphy
lococcus
aur
eus,
Clost
ri
dium per
fri
ngi
ns,
Prot
eusandAcet
obact
eret
c.
Themostpr
eval
entbact
eri
um i
nski
ngl
andsi
sthegr
am posi
ti
ve,anaer
obi
c,
l
i
pophi
l
ic,
rod‘
propi
onibact
eri
um acnes’
whi
chcausesaski
ndi
sease‘
AcneVul
gar
is’
or
‘
Acne’
.
Nor
malFl
oraoft
heNoseandNasophar
ynx:
Thenor
malf
lor
aoft
henosei
sfoundj
usti
nsi
det
henar
es. St
aphy
lococcus
eus and S.Epi
aur der
midi
s. The nasophar
ynx may cont
ain smal
lnumber
s of
st
rept
ococcuspneumoni
a.Nei
sser
iameni
ngi
ti
desandHaemophi
l
usi
nfl
uenza.
Nor
malFl
oraoft
heRespi
rat
oryTr
act
:
Theupperandl
owerr
espi
rat
oryt
ract
sdonothav
eanor
malmi
crobi
ota.The
t
rachea,br
onchiandl
ungsar
epr
otect
edbyt
heact
ionofci
l
iar
yepi
thel
i
alcel
l
sandt
he
mov
ementofmucus.Thet
issuesoft
hesest
ruct
uresar
enor
mal
l
yst
eri
l
easar
esul
tof
t
hispr
otect
iveact
iveandmi
croor
gani
smsar
eal
sor
emov
edbyphagocy
tot
icact
ionof
t
heal
veol
armacr
ophages.
Nor
malFl
oraoft
heMout
h(Or
alCav
ity
):
Thenor
malmi
crobi
otaoft
heor
alcav
itycont
ainsor
gani
sms,bi
ndt
othebuccal
mucosa,gumsandt
oot
hsur
faces.Themi
crobi
otaofmout
hconsi
stsmost
lyoft
he
gener
aSt
rept
ococcus,Nei
sser
ia,Act
inomy
ces,Vei
l
lonel
l
aandLact
obaci
l
lus. Some
y
east
sar
eal
sof
ound. Mostmi
croor
gani
smst
hati
nvadet
heor
alcav
ityi
nit
ial
l
yar
e
aer
obes.(
Eg.St
rept
ococcalsps) and obl
i
gat
e anaer
obes. Eg:Fusobact
eri
um,
Pr
evot
ell
a.
St
rept
ococcusgor
doni
iandS.mut
ansat
tacht
heenamelsur
facesoft
het
eet
h.
S.Sal
i
var
iusat
tachest
othebuccalandgi
ngi
valepi
thel
i
alsur
faceandcol
oni
zest
he
sal
i
va.Thepr
esenceoft
hesebact
eri
acont
ri
but
est
otheev
ent
ualf
ormat
ionofdent
al
pl
aque,
dent
alcar
ies(
or)Toot
hdecay
,gi
ngi
vi
ti
sandper
iodont
aldi
sease.
Nor
malFl
oraoft
heEy
e:
Atbi
rt
handt
hroughouthumanl
i
fe,bact
eri
alcommensal
sar
efoundont
he

2
conj
uct
iva oft
heey
e. Thepr
edomi
nantbact
eri
um i
sst
aphy
lococcusepi
der
midi
s
f
oll
owed by S.Aur
eus,aer
obi
c cor
ynebact
eri
a(di
pht
her
oids)and st
rept
ococcus
pneumoni
ae.Cul
tur
esf
rom t
heey
eli
dsorconj
uct
ivaal
soy
iel
dBr
anhamel
l
acat
arr
hal
i
s,
Escher
ichi
a,Kl
ebsi
ell
a,Pr
oteus,Ent
erobact
er,Nei
sser
iaandBaci
l
lusspeci
es. Few
anaer
obesar
epr
esent
.
Nor
malFl
oraoft
heEar
:
The basi
c mi
crobi
ota ofearconsi
sts ofcoagul
ase negat
ive st
aphy
lococci
,
cor
ynebact
eri
um andl
essf
requent
lyf
oundar
eBaci
l
lus,Mi
crococcus,Nei
sser
iasps.
Gr
am Negat
iver
odssuchaspr
oteus,Escher
ichi
a,Pseudomonasandsomef
ungil
i
ke
Asper
gil
l
us,
Alt
ernar
ia,
Peni
cil
l
ium,
Candi
daandSacchar
omy
cesar
eal
sof
ound.
Nor
malFl
oraoft
heGast
roI
ntest
inalTr
act
:
Atbi
rt
hthei
ntest
inei
sst
eri
l
ebutor
gani
smsar
esooni
ntr
oducedwi
thf
ood.Di
et
hasamar
kedi
nfl
uenceont
her
elat
ivecomposi
ti
onoft
hei
ntest
inal
andf
aecal
flor
a.
Thehumangast
roi
ntest
inal
tractcanbedi
vi
dedi
nto3maj
orr
egi
ons.
1.St
omach
2.Smal
lInt
est
ine
3.Lar
geI
ntest
ine
1.St
omach:Al
thought
hest
omachconst
ant
lyr
ecei
vesnumer
ousbact
eri
afr
om t
he
or
alcav
ity
,thef
lui
dcont
ent
soft
heheal
thyst
omachgener
all
ycont
ainl
esst
han10
bact
eri
apermi
l
li
li
terbecauseoft
hebact
eri
cidalef
fectoft
heHCL(
Hydr
ochl
ori
c
aci
d)i
nthegast
ri
csecr
eti
ons. Thef
ew or
gani
smsf
oundar
elact
obaci
l
liand
y
east
ssuchascandi
daspeci
es.
2.Smal
lInt
est
ine:Thesmal
lint
est
inei
sdi
vi
dedi
nto3ar
easDuodenum,Jej
unum
andI
leum. Duodenum i
sadj
acentt
ost
omachandr
esembl
esst
omachi
nit
s
mi
crobi
alf
lor
a. Jej
unum i
s mi
ddl
e por
ti
on oft
he smal
lint
est
ine cont
ains
Ent
erococcusf
aecal
i
s,Lact
obaci
l
li
,di
pht
her
oidsandcandi
daal
bicans. I
nthe
di
stalpor
ti
on(
Il
eum)oft
hesmal
lInt
est
ine,t
hef
lor
aresembl
etot
hatoft
hel
arge
i
ntest
ine.Fewanaer
obi
cbact
eri
aandEnt
erobact
eri
aceaemember
sar
efound.
3.Lar
geI
ntest
ine:Thecol
onhast
hel
argestmi
crobi
alpopul
ati
oni
nthebody
.Ov
er
300di
ff
erentspeci
eshav
ebeeni
sol
atedf
rom humanf
eces.
Themi
crobi
otaofl
argei
ntest
ineconsi
stsoff
acul
tat
ivel
yanaer
obi
cbact
eri
a

3
suchasE.col
i
,anaer
obi
cbact
eri
a(baci
l
li
)pr
esenti
ncl
udespeci
esofBact
eroi
dsand
Fusobact
eri
um.TheGr
amposi
ti
vebaci
l
liar
epr
esentEg:Bi
fi
dobact
eri
um,Eubact
eri
um
andLact
oaci
l
lus.Thef
acul
tat
ivel
yanaer
obi
cspeci
esf
oundi
nint
est
inebel
ongt
othe
gener
aEscher
ichi
a,Pr
oteus,
Klebsi
ell
aet
c.Pept
ost
rept
ococci(
anaer
obi
cst
rept
ococci
)
ar
ecommon.Somepr
otozoansmayal
sooccurascommensal
sint
hei
ntest
ine.Eg:
Tr
ichomonashomi
nis,
Ent
amoebahar
tmanni
,Endol
i
maxnanaet
c.
Nor
malFl
oraoft
heGeni
tour
inar
yTr
act
:
Theuppergeni
tour
inar
ytr
act(
kidney
s,ur
inar
ybl
adderandur
eter
s)i
susual
l
yfr
ee
ofmi
croor
gani
sms.I
nthemal
eandf
emal
e,af
ewbact
eri
ast
aphy
lococcusepi
der
midi
s,
Ent
erococcusf
aecal
i
sandCor
ynebact
eri
um speci
esar
eusual
l
ypr
esenti
nthedi
stal
por
ti
on of t
he ur
ethr
a. Nei
sser
ia, Chl
amy
dia, My
copl
asmas and some
Ent
erobact
eri
aceaemember
sar
eal
sof
ound.
Thenor
malf
lor
apl
aysani
mpor
tantr
olei
nbot
hheal
thanddi
sease.Er
adi
cat
ion
oft
henor
malf
lor
a mayhav
epr
ofound negat
iveef
fect
s,and y
et,manycommon
i
nfect
ionsar
ecausedbymember
soft
henor
malf
lor
a.Knowl
edgeoft
heseor
gani
sms
i
simpor
tantt
otheunder
standi
ngoft
hecol
l
ect
ionandpr
ocessi
ngofspeci
mensaswel
l
ast
hei
dent
if
icat
ionofi
sol
ates.
i
i. PROPERTI
ESOFPATHOGENI
CMI
CROORGANI
SMS
(
INFECTI
ON,
VIRULENCE,
PATHOGENI
CITY)

Theat
tachment
,ent
ry,gr
owt
handmul
ti
pli
cat
ionofapar
asi
te(
or)pat
hogen
wi
thi
noront
hehostt
issuesi
scal
l
edi
nfect
ion. Thet
ermi
nfect
ion(
Lat
ini
nfect
ion
meanst
oinf
ect
)andr
elat
edf
ormsoccur
smor
efr
equent
lyi
nmostdi
scussi
onsof
mi
crobi
aldi
seases.I
nfect
ionl
eadst
odi
seasebutnotal
li
nfect
ionscausedi
sease.
TheSt
epsi
nvol
vedi
ninf
ect
ion:
Tr
ansmi
ssi
onoft
hepar
asi
tef
rom anext
ernal
sour
cet
othehost
.
Adhesi
onoft
hepat
hogent
ocol
oni
set
hehost
.
Col
oni
sat
ionori
nvasi
onoft
hepar
asi
te.
Damaget
othehostduet
oit
stoxi
nsori
nvasi
on
Di
seasepr
ogr
essi
on.
Pr
ocessofI
nfect
ion:

4
 Bet
ween ent
ry oft
he or
gani
sms i
nthe body and appear
ance ofcl
i
nical
sy
mpt
oms,t
her
eisani
nter
valcal
l
edt
hei
ncubat
ionper
iod. Dur
ingt
hisper
iodt
he
or
gani
sm mul
ti
plyandf
act
orsnecessar
yformul
ti
pli
cat
ionar
efol
l
ows:

Sour
ce

Suscept
ibl
eHost MeansofTr
ansmi
ssi
on
Ty
pesofI
nfect
ions:
I
nfect
ionsmaybecl
assi
fi
edi
nvar
iousway
s.Theyar
e
(
a)Pr
imar
yInf
ect
ion:I
tisani
nit
iali
nfect
ionwi
thapar
asi
tet
hatal
l
owst
hef
urt
her
i
nvasi
onbysomemi
croor
gani
smsorot
heror
gani
smsi
scal
l
edPr
imar
yinf
ect
ion.
(
b)Rei
nfect
ion:Subsequenti
nfect
ion byt
he same par
asi
tei
nthe hosti
s cal
l
ed
Rei
nfect
ion.
(
c)Secondar
yInf
ect
ion:Whenanew par
asi
tei
nfect
sthehostwhoser
esi
stancei
s
l
ower
ed bypr
imar
yori
nit
iali
nfect
ion. (
i.
e.i
nfect
ionest
abl
i
shed af
terpr
imar
y
i
nfect
ion.
(
d)Mi
xedI
nfect
ion:I
nfect
ioni
nwhi
chmor
ethanoneor
gani
sm orki
ndsofmi
cro
or
gani
smsar
einv
olv
ed.
(
e)Local
isedI
nfect
ion:Rest
ri
ctedt
oal
i
mit
edar
eaoft
hebody(
inf
ect
ionl
i
mit
edt
o
poi
ntofent
ry)
.Ex-boi
lwar
t
(
f)FocalI
nfect
ion:I
tisal
ocal
i
zedor(
spr
eadst
oanewl
ocat
ion)chr
oni
cinf
ect
ioni
nthe
body
.Eg:t
eet
h,t
onsi
l
li
ti
s,accessor
ynasalsi
nuses,r
abi
es,hepat
it
isA,appendi
cit
is
et
c.suchani
nfect
ionmaypr
oducev
aguephy
sicalorment
aldi
stur
bancesand
al
l
ergi
creact
ions.
(
g)Cl
ini
cal
:Ani
nfect
iousonet
hati
str
ansmi
ssi
blef
rom pat
ientt
opat
ientbyt
ransf
erof
t
hecausat
iveor
gani
smsandani
nfect
iouspat
ienti
sonef
rom whom suchadi
sease
canbeacqui
red.
(
h)Sub-
cli
nical
:Whent
her
eisnoorl
i
ttl
eimpai
rmentt
hepat
ient
sheal
th.
(
i)Lat
ent
:di
seasesmaybei
nact
ivef
orl
ongper
iodsoft
imeEx-
Col
d,sor
est
hroat
,
geni
tal
her
pes.

5
 (
j)Gener
ali
sedorSy
stemi
cInf
ect
ion:I
nfect
iont
hatspr
eadst
hroughout(
inf
ect
iont
hat
spr
eads t
o sev
eralsi
tes and t
he body
)the body
.Ex-
Toot
h abscess,measl
es,
chi
ckenpox,
syphi
l
is.
(
k)Ful
minat
ing I
nfect
ion:I
nfect
ion t
hatoccursuddenl
y and t
he i
nfect
ious agent
mul
ti
pli
eswi
thsev
erei
ntensi
ty.
(
l)Cr
ossI
nfect
ion:Whenanew i
nfect
ioni
ssetupf
rom anot
herpat
ientorext
ernal
sour
cet
oaper
sonwhoi
sal
readysuf
fer
ingf
rom adi
sease.
(
m) Acut
eInf
ect
ion:I
thas di
seases dev
elop f
astbutf
ora shor
tdur
ati
on.
Ex-
I
nfl
uenza,
col
d.
(
n)Chr
oni
c:I
thasdi
seasesdev
elopsl
ow butf
oral
ongdur
ati
onl
ongdur
ati
on.
Ex-TB,
l
epr
osy
.
(
o)ExogenousI
nfect
ion:Whent
hesour
ceofi
nfect
ioni
sfr
om t
heext
ernalsour
ce,i
tis
cal
l
edexogenousi
nfect
ion.Themosti
mpor
tantsour
ceofhumani
nfect
ioni
sot
her
humans.Some agent
s(e.
g.measl
es)ar
e mor
etr
ansmi
ssi
blet
han ot
her
s.An
epi
demi
corout
breakcanoccuri
feachi
nfect
edi
ndi
vi
dualt
ypi
cal
l
ytr
ansmi
tst
he
pat
hogent
omor
ethanoneaddi
ti
onal
per
son.

(
p)EndogenousI
nfect
ion:Whent
hesour
ceofi
nfect
ioni
sfr
om host
’sownbody
,iti
s
cal
l
edEndogenousi
nfect
ion.

 Nosocomi
alI
nfect
ion:Cr
ossi
nfect
ionsoccur
ri
ngdur
inghospi
tal
stayar
ecal
l
ed
nosocomi
ali
nfect
ion.Ent
erobact
eri
aceaeandnon-
spor
inganaer
obessuch
asBact
eroi
desf
ragi
l
iscani
nvadet
heper
it
oneal
cav
itycausi
ngper
it
oni
ti
sand
sept
icaemi
a.
 I
nhal
ati
onofst
omachcont
ent
smaycausepneumoni
a,possi
blyf
oll
owedbya
l
ungabscess.
 St
aphy
lococcusaur
eust
hatar
enor
mal
l
yfoundi
nthenosemaycausewound
i
nfect
ioni
finocul
atedi
ntoasur
gical
wound.
 Neut
ropeni
cpat
ient
sar
eespeci
all
ypr
onet
oinf
ect
ionf
rom or
gani
smsnor
mal
l
y
hel
dincheckbyt
hebody
'sdef
ences.
 Sur
ger
yandi
ntr
avenouscannul
ati
onal
l
owski
nor
gani
smst
oinv
ade.

I
nfect
iousDi
seases:

6
 Di
seasescausedbyi
nfect
ingmi
croor
gani
smsar
ecal
l
edi
nfect
iousdi
seases.Eg:
Chol
era,
Typhoi
d,AI
DSet
c.
Ty
pesofI
nfect
iousDi
seases:
Dependi
ng on t
hespr
ead ofi
nfect
iousdi
seasei
nthe communi
ty,t
heyar
e
cl
assi
fi
edi
ntodi
ff
erentt
ypes.
1. Endemi
cDi
sease:Descr
ibi
ngadi
seaseadi
seaset
hati
sal
way
spr
esenti
na
popul
ati
on.
2. Epi
demi
cDi
sease:Epi
demi
cdi
seaset
hataf
fect
sal
otofpeopl
eget
sadi
sease
i
nashor
tti
mei
nthesamear
ea.
3. Pandemi
cDi
sease:Di
seaset
hataf
fect
smanypeopl
eatdi
ff
erentcount
ri
es
(
wor
ldwi
de)
.
4. Spor
adi
cDi
sease:Adi
seaset
hatoccur
sonl
yoccasi
onal
l
yori
naf
ew i
sol
ated
pl
aces.Tr
ansmi
ssi
onofI
nfect
iousDi
seases:
Ther
ear
evar
iousmet
hodsorway
soft
ransmi
ssi
onofi
nfect
ions.Theyar
edi
rect
cont
act
,indi
rectcont
act
,Tr
ansmi
ssi
onbyi
ngest
ion,
transmi
ssi
onbyi
nocul
ati
onet
c.

Di
rectCont
actTr
ansmi
ssi
on:Aper
soncanbei
nfect
edbydi
rectcont
actwi
thi
nfect
ed
t
issueofanot
herper
son.Sexual
int
ercour
seal
l
owsor
gani
smswi
thpoorsur
viv
alabi
l
ity
out
sidet
hebodyt
obet
ransmi
tt
ed.Exampl
esi
ncl
udeNei
sser
iagonor
rhoeae,
Tr
eponemapall
idum andHI
V.Transmi ssi
onofHIVisenhancedbygeni
tal
ulcer
ati
on.
Eg:
Sexuall
ytr
ansmit
teddiseasesli
kesyphi
li
s,Gonorr
hoea,AI
DSetc.
a)I
ndi
rectCont
actTr
ansmi
ssi
on:I
nfect
ioncanbet
ransmi
tt
edbyt
hei
nani
mat
e
obj
ect
sli
kepenci
l
s,cl
othi
ng,t
oysandt
owel
set
cthatar
eusedbyt
hepat
ientor
car
ri
erEg:
Dipht
her
ia.
b)Tr
ansmi
ssi
onbyI
ngest
ion:I
nfect
ionsar
eal
sot
ransmi
tt
edbyt
hei
ngest
ionof
f
oodorwat
ercont
ami
nat
ionbypat
hogeni
cmi
croor
gani
smssuchi
nfect
ionsmay
bewat
erbor
neorf
oodbor
ne.Eg:
Chol
era.
Sour
cesofI
nfect
ion:
Humanbei
ngs,
ani
mal
s,i
nsect
s,dr
opl
etset
c.ar
ethesour
cesofi
nfect
ion.
1. Humanbei
ngs:Humanbei
ngi
sthecommonestsour
ceofi
nfect
ion.I
nthi
sthe
sour
cemaybei
nthef
orm ofacar
ri
erorapat
ient
.
Car
ri
er:Acar
ri
eri
saper
sonwhohar
bour
spat
hogeni
cor
gani
smswi
thoutany

7
si
gnorov
ertdi
seaseandhel
psi
ncommuni
cat
ionoft
hedi
seaset
oaheal
thyi
ndi
vi
dual
.
Aper
sonwhohar
bour
sthepat
hogensbutnev
ersuf
fer
edf
rom t
hedi
seasecausedby
t
hepat
hogeni
scal
l
edaheal
thycar
ri
er.Onewhohashar
bour
sthepat
hogenf
orl
ess
t
han6mont
hsi
scal
l
edat
empor
arycar
ri
er.
2. Ani
mal
s:Ani
mal
scanal
soactassour
ceofhumani
nfect
ionsuchani
mal
s
mai
ntai
nthepar
asi
tesi
nthem andactast
her
eser
voi
rsofhumani
nfect
ions.Eg:
Rabi
esdi
sease.
Dr
opl
etI
nfect
ion:I
nthi
scaseact
ualcont
acti
snotnecessar
y. Thei
nfect
ion
occur
sfr
om mi
nut
epar
ti
clesordr
opl
etsofsal
i
va,sput
um ornasalsecr
eti
ondur
ing
coughi
ng,sneezi
ngorspeaki
ng,suspendedi
ntheai
rasdr
opl
etnucl
eiwhi
chmay
cont
ainmi
croor
gani
smsandspr
eadouti
ntheai
r. Thei
nfect
ionst
akepl
acewhen
dr
opl
etsar
einhal
edbyani
ndi
vi
dual
.
3. I
nsect
s:I
nsect
sthatf
eedonbl
oodmayt
ransmi
tawi
der
angeofpat
hogens:
mosti
mpor
tant
lyf
emal
eanophel
enemosqui
toest
ransmi
tmal
ari
a.
Eg:Housef
lyt
ransmi
tmi
croor
gani
smst
hatcausedi
seasesl
i
ket
yphoi
ddy
sent
eryet
c.
Anophel
esmosqui
toesact
sasbi
ologi
calv
ect
orf
ormal
ari
aaspat
hogensmul
ti
pli
esi
n
t
hei
rbody
.

i
ii
. CHARACTERI
STI
COFEXOTOXI
NSANDENDOTOXI
NS

Pat
hogeni
cit
yandVi
rul
ence:
Thet
erms‘
pat
hogeni
cit
y’,‘
vi
rul
ence’r
efert
otheabi
l
ityofami
croor
gani
smst
o
pr
oducedi
seaseort
issuei
njur
y,butt
her
eisasl
i
ghtdemar
cat
ionbet
weent
het
wo
t
erms.
Pat
hogeni
cit
yisgener
all
yempl
oyedt
oref
ert
otheabi
l
ityofami
crobi
alspeci
es
t
opr
oducedi
sease.Whi
l
ethet
ermv
irul
encei
sappl
i
edt
othesamepr
oper
tyi
nast
rai
n
ofmi
croor
gani
sm,whi
chi
sal
soknownast
hedegr
eeofpat
hogeni
cit
y.Eg:Speci
esof
My
cobact
eri
um (
M.Tuber
cul
osi
s)i
sref
err
edt
oasbei
ngpat
hogeni
c. Butt
hesame
speci
es(
M.Tuber
cul
osi
s)cont
ainst
rai
nsofv
ary
ingdegr
eesofv
irul
encechar
act
er
i
ncl
udi
ngt
hosewhi
char
eav
irul
ent
,suchast
hev
acci
nest
rai
ns. Thev
irul
enceofa
st
rai
nisnotconst
ant
.Itmaybeexal
tedorat
tenuat
ed.

8
 Enhancementofv
irul
encei
sknownas“
exal
tat
ion”andcanbedemonst
rat
ed
exper
iment
all
ybyser
ialpassagei
nsuscept
ibl
ehost
s.Reduct
ionofv
irul
encei
sknown
as“
Att
enuat
ion”and i
tisdonebypassaget
hrough unf
avour
abl
e host
s,r
epeat
ed
cul
tur
esi
nar
ti
fi
cialmedi
a,gr
owt
hunderhi
ght
emper
atur
eori
nthepr
esenceofweak
ant
isept
ics,
desi
ccat
ionorpr
olongedst
oragei
ncul
tur
e.
Thev
irul
enceofapat
hogenusual
l
ymeasur
edbyt
heLet
hal
Dose(
LD)orMi
nimal
Let
halDose(
MLD)andt
heI
nfect
ionDose(
ID)et
c.Pat
hogeni
cit
yref
erst
othepot
ent
ial
capaci
tyt
ocausedi
seaseandi
sappl
i
edt
ogr
oupsorspeci
esofmi
croor
gani
sms.For
exampl
eSal
monel
l
aar
econsi
der
edt
obepat
hogensbecauset
heycanpr
oducedi
sease
i
nanani
mal
host
s.
Vi
rul
encef
act
orsar
ethepr
oper
ti
est
hatar
epr
esenti
nordev
elopedbypat
hogen
t
ofi
ghtagai
nsthostdef
encesy
stem.Thesev
irul
encef
act
orsar
eadher
encef
act
ors,
i
nvasi
veness,
toxi
geni
cit
yet
c.
Vi
rul
enceFact
ors:
Vi
rul
encef
act
orsar
ethepr
oper
ti
est
hatar
epr
esenti
nordev
elopedbypat
hogen
t
ofi
ghtagai
nsthostdef
encesy
stem.Thesev
irul
encef
act
orssucceedagai
nstt
hehost
r
esi
stanceori
mmunesy
stem causi
ngi
nfect
ions.
Themosti
mpor
tantv
irul
encef
act
orsar
etoxi
ns,
inv
asi
venessenzy
meset
c.
1. Toxi
ns:
At
oxi
nisanysubst
ancet
hati
spoi
sonoust
oot
heror
gani
sms.At
oxi
n(Toxi
cum
–poi
son)i
saspeci
fi
cpoi
sonoussubst
anceof
tenamet
abol
i
cpr
oductoft
heor
gani
sm,
t
hatdamagest
hehostatl
owconcent
rat
ion.Theyar
egener
all
ypr
otei
nsbutt
heymay
bel
i
pidsorot
hersubst
ances.
Somebact
eri
apr
oducet
oxi
ns,whi
char
esy
nthesi
zedi
nsi
debact
eri
alcel
l
sand
ar
ecl
assi
fi
edaccor
dingt
ohowt
heyar
erel
eased.Theyar
ecl
assi
fi
edi
nto.
a)Exot
oxi
nsand
b)Exdot
oxi
ns
A.Exot
oxi
ns:
Thesear
esol
ubl
esubst
ances,
heatl
abi
l
e,pr
otei
ntoxi
nst
hatar
erel
eased
f
rom t
he pat
hogen t
othe sur
roundi
ngs. Exot
oxi
ns ar
e mor
e power
fult
oxi
ns
pr
oducedbysev
eralgr
am posi
ti
veandaf
ew gr
am negat
ivebact
eri
a. Mostar
e
pol
ysacchar
ides,whi
char
edenat
uri
zedbyheat
,U.
Vli
ghtandchemi
cal
ssuchas

9
 f
ormal
dehy
de.Speci
esofcl
ost
ri
dium,Baci
l
lus,St
aphy
lococcus,St
rept
ococcusand
sev
eralot
herbact
eri
apr
oduceexot
oxi
ns.Exot
oxi
nsar
etoxi
cinv
erysmal
ldoses
andt
heyar
ehi
ghl
yimmunogeni
c.Exot
oxi
nsacti
nav
ari
etyofway
s.
a)I
nhi
bit
ionofPr
otei
nSy
nthesi
s
b)I
nhi
bit
ionofner
vesy
napsef
unct
ion
c)Damaget
opl
asmamembr
ane
Exot
oxi
nsmaybedi
vi
dedi
nto3cat
egor
ies,ont
hebasi
soft
hesi
teaf
fect
ed,
manyexot
oxi
nshav
easpeci
alat
tract
ionf
orpar
ti
cul
art
issues.Theyar
e
a)Neur
otoxi
n
b)Ent
erot
oxi
n
c)Cy
tot
oxi
n
B.Endot
oxi
ns:Theyar
epol
ysacchar
idesubst
ancesi
ntheout
ermembr
anel
ayeroft
he
cel
lwal
l
sofGr
am negat
ivebact
eri
a.Theyar
erel
easedaf
tert
hel
ysi
soft
hecel
l
s
onl
y.So,t
hesear
elessef
fect
ivet
hanexot
oxi
ns.Theyar
eact
iveonl
yinr
elat
ivel
y
l
argedosesandt
heyar
eweakl
yimmunogeni
c.Endot
oxi
nsar
ecapabl
eofcausi
ng
f
ever
,leukopaeni
a,i
ntest
inal
hemor
rhage,
endot
oxi
cshocket
c.
2. Toxi
ns:
Theabi
l
ityofapat
hogent
ospr
eadi
nthehostt
issuesaf
terest
abl
i
shi
ngt
he
i
nfect
ioni
sknownasi
nvasi
veness.Hi
ghl
yinv
asi
vepat
hogenspr
oducespr
eadi
ngor
gener
ali
zed i
nfect
ions. For Eg:St
rept
ococcalsept
icaemi
a whi
l
eless i
nvasi
ve
pat
hogenspr
oducel
ocal
i
zedi
nfect
ions.Eg:St
rept
ococcalabscess.Somepat
hogens
ar
eabl
etocauseser
iousorf
ataldi
seasesandt
heydonothav
einv
asi
veness. Eg:
t
etanusbaci
l
libutpr
oducepot
entt
oxi
ns.
3.Vi
rul
ence:
Thev
irul
encef
act
orofapat
hogeni
susual
l
ymeasur
edbyt
heLD,
MLDorI
Det
c.
a)MLD:Themi
nimum numberofbact
eri
arequi
redt
opr
oducecl
i
nicalev
idenceof
deat
hinasuscept
ibl
eani
mal
underst
andar
dcondi
ti
oni
scal
l
edMLD.
b)MI
D:Themi
nimum numberofbact
eri
arequi
redt
opr
oducecl
i
nicalev
idenceof
i
nfect
ioni
nsuscept
ibl
eani
malunderst
andar
dcondi
ti
oni
scal
l
edMI
D orI
D.
Vi
rul
encef
act
ori
sof
tenmeasur
edexper
iment
all
ybydet
ermi
ngt
hel
ethaldose
50(
LD50)ort
hei
nfect
ivedose50(
ID50)
.Thesev
aluesr
efert
othedoseor

10
 numberofpat
hogens t
hatwi
l
lei
therki
l
lori
nfectr
espect
ivel
y50% ofan
exper
imentgr
oupofhost
swi
thi
naspeci
fi
edt
imeper
iod.
4.Enzy
mes:
Cer
tai
nenzy
mespr
oducedbyt
hepat
hogensal
soai
dinpat
hogeni
cit
y. Some
exot
oxi
nsar
eenzy
mes. Someoft
hem ar
ecoagul
ase,cat
alaseandhy
alur
oni
dase.
DNase,
leucoci
dins,
hemol
ysi
nset
c.
5.Capsul
arMat
eri
al:
Capsul
ated bact
eri
a such as Pneumococci
,Kl
ebsi
ell
a,Pneumoni
ae and
Haemophi
l
usi
nfl
uenzaar
enotr
eadi
l
yphagocy
tosedandcapsul
emaycont
ri
but
ethe
v
irul
ence.

STREPTOCOCCUSPYOGENES
MORPHOLOGY:
Gr
am posi
ti
vespher
ical
cocci
arr
angedi
nchai
ns,
theyar
enon-
mot
il
e,non-
spor
ingandcapsul
ated.
CULTURALCHARACTERS:
- Facul
tat
iveanaer
obes.
- Opt
imum t
emper
at e37oC
ur
- Fast
idi
ousdonotgr
owonNAorgr
owsonl
ypoor
ly
- OnBAi
tpr
oduces-
haemol
yti
ccol
oni
eswhi
char
esmal
l
,ci
rcul
ar,
transpar
ent
l
owconv
ex.Haemol
ysi
senhancedby5–10%CO2.
- Thosewi
thwel
lpar
kedcapsul
espr
oducemucoi
dcol
oni
es
- Sel
ect
ivemedi
aiscr
yst
alv
iol
etbl
oodagar
.

- I
nli
qui
dmedi
agr
owt
hoccur
sasgr
anul
art
urbi
dit
ywi
thpowder
ydeposi
t.

BI
OCHEMI
CALREACTI
ONS:

- Theyf
ermentsugar
s(l
act
ose,
mal
tose,
dext
ri
nmanni
tol
,sor
bit
ol,
trehal
oge)wi
th
aci
d,nogas

- Theyar
ecat
alase–(
ive)

11
AgofSt
rept
ococci
:
1)Capsul
eisnotant
igeni
c,i
tinhi
bit
sphagocy
tosi
s
2)Out
erl
ayeroff
imbr
iacont
aini
ngpr
otei
nandl
i
pot
eichoi
caci
d.
3)Gr
oupspeci
fi
cC.Car
bohy
drat
eAg.
- I
tisani
ntegr
alpar
tofcel
lwal
l
.
4)Pr
otei
nAgpr
esentoncel
lwal
lar
eM,
T,R,
‘M’
prot
eini
smosti
mpor
tantoft
hese
andhel
psi
nat
t entofSt
acheni rept
ococcit
ohostcel
l
s.
- I
tact
sasv
irul
encef
act
orbyi
nhi
bit
ingphagocy
tosi
s.
- I
tisant
igeni
candant
ibodi
est
o‘M’
prot
einpr
omot
ephagocy
tosi
s.(
Ther
efor
e
pr
otect
ive)
- I
tisheatandaci
dst
abl
e.
PATHOGENESI
S
Di
seasespr
oducedar
e
(
1)Respi
rat
oryi
nfect
ion Phar
yngi
ti
s
Tonsi
l
li
ti
s
(
2)Ski
ninf
ect
ions
(
3)Subcut
aneousi
nfect
ions
(
4)Geni
tal
inf
ect
ions
(
5)Suppur
ati
vei
nfect
ions
6)PostSt
( rept
ococcalsequel
aeornon-
suppur
ati
vecompl
i
cat
ions
(
1)Sor
eThr
oat
:
 I
ti hecommonestSt
st rept
ococcaldi
sease
 Whenl
ocal
i
sedi
scal
l
edt
onsi
l
li
ti
s,i
scommoneri
nol
derchi
l
drenandadul
tst
hani
n
y
oungerchi
l
dren.
 Sor
ethr
oatmayi
nvol
vephar
ynxmor
edi
ff
usel
ytocausephar
yngi
ti
s.
 St
rept
ococciat
tachesbymeansofi
tsl
i
pot
eichoi
caci
dcov
eri
ngt
hesur
facepi
l
i.
Theyat
tacht
hemsel
vest
ogl
ycopr
otei
nrecept
orsont
her
espi
rat
oryepi
thel
i
alcel
l
s.

Compl
icat
ionsofSor
eThr
oat
:
Fr
om t
hroat
,theycanspr
eadt
osur
roundi
ngt
issuesl
eadi
ngt
oot
it
ismedi
a,
mast
oidi
ti
s suppur
ati
ve adeni
ti
s. St
rept
ococcal pneumoni
a may occur as a

12
compl
i
cat
ionofi
nfl
uenzaorot
herr
espi
rat
oryv
iral
inf
ect
ions.
SKI
NINFECTI
ONS:
a)I
mpet
igo:St
rept
ococcit
hatcausei
mpet
igoar
eder
ivedmai
nlyf
rom ski
nlesi
onson
ot
herper
sons.
b)Er
ysi
pel
as:
- I
tisr
arert
hani
mpet
igo,
aff
ect
susual
l
yel
der
ly.
- I
nfect
edar
easshowedemaander
ythema.
- I
tmaybeduet
ohy
per
sensi
ti
vi
tyofper oSt
sont rept
ococcalpr
oduct
s.
Subcut
aneousI
nfect
ion:
- Somest
r nsofSt
ai rep.Py
ognenesi
.eM t
ypeIst
rai
nsf
ormi
ngpy
rogeni
cex
otoxi
n
Acont
ri
but
etonecr
oti
singf
asci
i
tis.
Puer
per
alSepsi
s:Si
ncet
heyoccurasnor
mali
nhabi
tansoff
emal
egeni
talt
ract
,
t
heycausedpuer
per
alsepsi
sorchi
l
dbedf
everwhi
cht
ookheav
ytoi
lofl
i
fedur
ing
pr
eant
ibi
oti
cer
a.
Suppur
ati
vei
nfect
ions:Theymaycausesabcessesi
nint
ernalor
ganssuchas
br
ain,
lung,
li
ver
,ki
dneyandal
sosept
icemi
a.
Nonsuppur
ati
vecompl
i
cat
ionsar
eRFandAGN.
Rheumat
icFev
er(
RF)
:
Anat
tackofRFi
srel
atedt ecedentSt
oant rept
ococcalt
hroati
nfect
ionoccur
ri
ng1-
5
wks ear
li
er.Suppor
tfor t
his associ
ati
on i
s based on cl
i
nical
,bact
eri
ologi
cal
,
epi
demi
ologi
cal
,ser
ologi
cal
andchemopr
ophy
lact
icev
idence.

EPI
DEMI
OLOGY:
- Sour
ceofi
nfect
ion–Pat
ient
sandcar
ri
ers.St
rept
ococciar
ecar
ri
edi
nthet
hroat
,
nasophar
ynxandnose.
- Sy
mpt
oml
essi
nfect
ioni
scommon.
ModeofTr
ansmi
ssi
on:
a)Di
rectcont
act
b)Cont
ami
nat
eddust
c)Thr
oughf
omi
tes
Ov
ercr
owdi
ngf
avour
str
ansmi
ssi
onofi
nfect
ion

13
LABORATORYDI
AGNOSI
S:
Acut
eInf
ect
ion - Di
agnosi
sest
abl
i
shedbycul
tur
e
Nonsuppur
ati
vecompl
i
cai
tons- Di
agnosi
sisbasedondemoofAbt
o
St
rept
ococcalAg
Speci
mens:
1)Thr
oatswab
2)Swabsf
rom ski
nlesi
ons
3)CSF
4)Ser
um f
ordet
ect
ionofAb
PRESUMPTI
VEDI
AGNOSI
S:
Pr
esenceofGPCi
nchai
nsi
npusandCSFi
sindi
cat
iveofSt
rept
ococcali
nfect
ion.
Buti
tisofnov
aluei
nthr
oatswabwher
etheor
gani
smsf
orm apar
tofnor
mal
flor
a.
MEDI
AUSEDFORCULTURE:
Cr
yst
alv
iol
etbl
ood agari
sasel
ect
ivemedi
um. Af
terpl
ati
ng i
tshoul
d be
i edat37oCunder5-
ncubat 10%CO2.
Col
onyMor
phol
ogy
:
-haemol
yti
csmal
ltr
ansl
ucentcol
oni
es.
St
rept
ococcalGr
oupi
ngcanbedoneby
Mi
croni
tr
ousaci
dext
ract
ionmet
hod
Lancef
iedhotaci
dext
ract
ionmet
hod
oupASt
Gr rept
ococciar
euni
for
mlysuscept
ibl
etobaci
tr
aci
n.
SEROLOGI
CALTESTS:
Ant
i-
Str
ept
oly
sinO (
ASO)det
ect
ionar
edonebyCA orbymi
crot
it
remet
hod
usi
ngr
abbi
tRBC.Ti
tr
eabov
e240I
Uinchi
l
drenand340I
U’nadul
tsar
esi
gni
fi
cantof
postSt
rept
ococcalsequel
ae.
Ant
iDNAseB:Ti
tr
eabov
e800I
Uar
esi
gni
fi
cant
.
Ant
ihy
alur
oni
dase:A-DNAaseBandant
ihy
alur
oni
daset
est
sar
ever
yusef
ulf
or
r
etr
ospect
ivedi sofSt
agnosi rept
ococcalr
einf
ect
ionandf
urt
herdamaget
ohear
t.
TREATMENT:
Peni
cil
l
ini
sthedr
ugofchoi
ce(
ifal
l
ergi
c)Er
ythr
omy
cinorCephal
exi
nar
eused.

TUBERCULOSI
S

14
I
NTRODUCTI
ON:
Tuber
cul
osi
sisachr
oni
cgr
anul
omat seasecausedbyMy
ousdi cobact
eri
um
t
uber
cul
osi
sinmanbutsomecasesar oM.bov
eduet iswhi
chi
sthepr
inci
palcauseof
t
uber
cul
osi
sincat
tl
eand manyot
hermammal
s.Rober
tKoch(
1882)i
sol
ated t
he
t
uber
clebaci
l
liandpr
ovedi
tset
iol
ogyorpat
hogenesi
s.

Mor
phol
ogy
:
My
cobact
eri
um t
uber
cul
osi
sisast
rai
ghtorsl
i
ght
lycur
vedr
od,measur
esabout
1–4m x0.
2–0.
8m occur
ri
ngsi
ngl
y,i
npai
rsori
nsmal
lcl
umps.I
tisnon-
mot
il
e,non
capsul
ated,nonspor
ing,aci
dfastbact
eri
um.Duet
othepr
esenceofmy
col
i
caci
dsi
n
t
hecel
lwal
l
,theyr
esi
stdecol
our
isat
ionby20%H2SO4orabsol
uteal
cohol
.
Cul
tur
alChar
act
eri
sti
cs:
Thebaci
l
ligr
ow sl
owl
y,t
hegener
ati
ont
imei
nvi
tr
obei
ng14-
15hr
s. Col
oni
es
appearonl
yinaboutt
woweeks.Opt
imum t
emper
atur
erequi
redf
orgr
owt
his37oCand
gr
owt ow 25oCorabov
hdoesnotoccurbel e40oC.Opt
imum PH i
s6.
4to7.
0.Sev
eral
sol
i
dandl
i
qui
dmedi
aar
eav
ail
abl
efori
tscul
ti
vat
ion. Thesol
i
dmedi
amostwi
del
y
empl
oyedf
orr
out
inecul
tur
eist
heLowenst
ein–Jensen(
LJ)medi
um. LJmedi
um
consi
stsofcoagul
atedhen’
segg,mi
ner
alsal
tsol
uti
on,mal
achi
tegr
een,aspar
gineand
mal
achi
tegr
een,actasasel
ect
iveagenti
nhi
bit
ingot
herbact
eri
a. I
tisanobl
i
gat
e
aer
obe.Gr
owt
hisst
imul
atedby5–10%CO2and0.
5%gl
ycer
ol.
Ant
igeni
cPr
oper
ti
es:
Manyant
igenshav
ebeeni
dent
if
iedi
nMy
cobact
eri
a.Gr
oupspeci
fi
cit
yisduet
o
pol
ysacchar
idesandt
ypespeci
fi
cit
ytopr
otei
nant
igens.Pr
otei
ns(
tuber
cul
i
n)oft
he
baci
l
luscausedel
ayedhy
per
sensi
ti
vi
ty.
PATHOGENESI
S:
- Pr
imar
ytuber
cul
osi
s:Thesi
teofi
nit
iali
nfect
ioni
susual
l
ythel
ungf
oll
owi
ngt
he
i
nhal
ati
onofbaci
l
li
.Thesebaci
l
liar
eengul
fedbyal
veol
armacr
ophagesi
nwhi
ch
t
heyr
epl
i
cat
etof
ormi
nit
iall
esi
onorGohnf
ocus.Somebaci
l
liar
ecar
ri
edi
n
macr
ophagest
ohi
l
arl
ymphnodes.Gohnf
ocuswi
thenl
argedhi
l
arl
ymphnodes
f
ormt
hepr
imar
ycompl
ex.
- Tuber
clef
ormat
ion:Wi
thi
nabout10day
sofi
nfect
ion,cl
onesofAgspeci
fi
cT

15
 l
ymphocy
tes ar
e pr
oduced whi
ch r
elease l
ymphoki
nes t
hat act
ivat
e
macr
ophageswhi
chf
orm acompactcl
ust
erorgr
anul
omaar
oundt
hef
ociof
i
nfect
ion.Theseact
ivat
edmacr
ophagesar
eter
medepi
thet
oidcel
l
sduet
othei
r
mi
croscopi
calr
esembl
ancet
o epi
thl
oid cel
l
s. Someoft
hem f
uset
ofor
m
mul
ti
nucl
eat
egi
antcel
l
s.Thecent
reoft
hegr
anul
omacont
ainsnecr
osedt
issue
anddeadmacr
ophageswhi
chf
ormi
tscheesel
i
keappear
anceandconsi
stency
i
sref
err
edt
oascaseat
ion.
- Mi
ll
iar
ytuber
cul
osi
s:I
faf
ocusi
ntoabl
oodv
essel
,baci
l
liar
edi
ssemi
nat
ed
t
hroughoutt
hebodywi
tht
hef
ormat
ionofnumer
ousgr
anul
omasknownas
mi
l
itar
ytuber
cul
osi
s.

Cl
ini
calf
eat
ures

Mycobact
eri
um tuber
cul
osis mayaf fectev
eryor
gan oft
he bodymi
micki
ng bot
h
i
nfl
ammatoryandmali
gnantdiseases.

 Pul
monar
y:chr
oni
ccough,haemopt
ysi
s,f
everand wei
ghtl
oss,orr
ecur
rent
bact
eri
alpneumoni
a.I
funt
reat
ed,
itf
oll
owsachr
oni
c,det
eri
orat
ingcour
se.
 Meni
ngi
ti
s:f
everanddet
eri
orat
ingl
evel
ofconsci
ousness.
 Renal
:si
gnsofl
ocali
nfect
ion,f
everandwei
ghtl
oss,compl
i
cat
edbyur
eter
ic
f
ibr
osi
sandhy
dronephr
osi
s.
 Bone:t
hel
umbosacr
alspi
nei
sacommonsi
teofi
nfect
ion.Compl
i
cat
edby
v
ert
ebr
alcol
l
apseandner
vecompr
essi
on.Pusmayspr
eadundert
hepsoassheat
hto
appeari
nthegr
oin(
psoasabscess)
.
 Joi
nts:
inf
ect
slar
gej
oint
scausi
ngdest
ruct
ivear
thr
it
is.
 Abdomi
nal
:mesent
eri
cly
mphadenopat
hyandchr
oni
cper
it
oni
ti
smaypr
esentas
f
ever
,wei
ghtl
oss,
asci
tesandi
ntest
inal
mal
absor
pti
on.
 Mi
l
iar
ydi
sease:
mayoccurwi
thoutev
idenceofact
ivel
ungi
nfect
ion.

LABORATORYDI
AGNOSI
S

Awi
der
angeofspeci
menscanbeexami
ned,
usi
ngav
ari
etyoft
echni
ques.

 Di
rectst
aini
ngwi
thZi
ehl
-Neel
sen'
smet
hodoraur
ami
ne.
 Cul
tur
eonl
i
pid-
ri
ch(
egg-
cont
aini
ng)medi
um wi
thmal
achi
tegr
een(
Löwenst
ein-
JensenorL-
Jmedi
um)t
osuppr
essot
heror
gani
sms.

16
 Aut
omat
edgr
owt
hdet
ect
ion,
whi
chcanspeedi
sol
ati
on.
 Suscept
ibi
l
ityi
susual
l
ytest
edi
naut
omat
edsy
stems(
e.g.My
cobact
eri
alGr
owt
h
I
ndi
cat
orTest[
MGI
T])
.
 Nucl
eic aci
d ampl
i
ficat
ion t
est
s(NAATs) t
hat i
ncl
ude det
ect
ion of dr
ug
r
esi
stancemut
ati
onsal
l
owr
api
dident
if
icat
ionofpat
ient
swi
thmul
ti
drugr
esi
stanceTB
(
MDRTB)sot
heycanbei
sol
atedandappr
opr
iat
elyt
reat
ed.
 Ty
pingbyi
dent
if
icat
ionoft
henumberofcopi
esof23r
epet
it
iveDNAel
ement
s.
 I
mmuni
tyi
s det
ermi
ned bymeasur
ing t
he ?
-i
nter
fer
on r
esponse t
o speci
fi
c
ant
igens(
Int
erf
eronGammaRel
easeAssay[
IGRA]
).

LABDI
AGNOSI
S:
1)Di
rectMi
croscopy
2)Cul
tur
e
3)Tr
ansmi
tt
ingi
nfect
iont
oani
mal
s
4)Demonst
rat
ionofhy
per
sensi
ti
vi
tyt
otuber
cul
opr
otei
n
SPECI
MENS:
Pul
monar
yTuber
cul
osi
s:
1)Sput
um
2)Lar
yngeal
swabs–whensput
um i
snotav
ail
abl
e
3)St
omachwashi
ngsorgast
ri
c-washi
ngs-
inchi
l
drenwhot
endt
oswal
l
owsput
um
4)Br
onchoscopi
cspeci
men
1)Sput
um:
Baci
l
lar
ysheddi
ngi
sabundanti
nlesi
onwi
thcaseat
ionandr
elat
ivel
yscant
lyi
n
mi
l
itar
yTB.Ear
lymor
ningsput
um shoul
dbecol
l
ect
edbef
oremeal
s. I
fsput
um i
s
scant
y24hrcol
l
ect
ionmaybeex
ami
ned.Thr
eeconsecut
ivesampl
eshoul
dbet
est
ed,
si
ncet
hesheddi
ngofbaci
l
lusi
nint
ermi
tt
ent
. Sput
um shoul
dbecol
l
ect
edi
nwi
de
mout
hedst
eri
l
econt
ainer
s.
Pr
event
ion
Thest
andar
dregi
menf
orpul
monar
yinf
ect
ioni
sri
fampi
cinandi
soni
azi
dfor6mont
hs,
wi
thet
hambut
olandpy
razi
nami
def
ort
hef
ir
st2mont
hs.Regi
mensf
orot
hersi
tesar
e
si
mil
ar,t
aki
ngi
ntoaccountdr
ugpenet
rat
ion(
e.g.i
ntoCSF)
.Ther
eisar
isi
ngt
rendof
MDRTB.Feat
urest
hatpr
edi
sposeapat
ientt
othi
sincl
ude:

17
  pr
evi
ousi
ncompl
etet
reat
ment
;
 bei
ngaknowncont
actofanMDRpat
ient
;
 r
esi
dencei
nacount
rywher
eMDRTBi
scommon;
 f
ail
uret
orespondt
oanadequat
eregi
men.

Tr
eat
mentofMDRTBi
scompl
ex,r
equi
ri
ngacombi
nat
ionofsecond-
li
neagent
s,such
as ami
nogl
ycosi
des, f
luor
oqui
nol
ones, et
hionami
de or cy
closer
ine, gui
ded by
suscept
ibi
l
ityt
est
s.
Vacci
nat
ionwi
that
tenuat
edbaci
l
leCal
met
te-
Guér
in(
BCG)st
rai
nmaypr
otectagai
nst
mi
l
iar
yspr
ead,
butt
ri
alsi
nsomecount
ri
eshav
eshownnobenef
it
.Pat
ient
sathi
ghr
isk
ofdev
elopi
ngt
uber
cul
osi
smaybegi
venpr
ophy
laxi
swi
thi
soni
azi
dandr
if
ampi
cin.

TREATMENT:
I
tconsi
stsofbedr
est
,fr
eshai
r,goodf
oodandchemot
her
apy
.
Mul
i
tpl
edr
ugt
her
apyhast
obef
oll
owed– gener
all
y3dr
ugssi
mul
tancousl
y
pr
olonged t
reat
mentf
or2 or3 y
ear
sist
he r
ule,somet
imes wi
thr
if
ampi
ci
n(a
bact
eri
cidal
drug)6mont
hscour
sfoundadequat
e.
Dr
ug r
esi
stance i
sver
y common.Dr
ugs used ar
eri
fampi
cin,i
soni
azi
d,
py
razi
niami
de,
str
ept
omy
cin,
ethambut
ol,
Cycl
oser
ineet
c.

STAPHYLOCOCCUSAUREUS
1.Mor phology
Theyar esmal lGram positi
vecocciabout0. 5–1µm i ndiameter
,spheri
calinshapear rangedingrape
l
ikeSt ructure,Clusterformationi sduet ocelldivisionoccurr
ingint hr
eepl anes,withdaught ercell
s
remainingi nclosepr oximit
y.
2.CulturalChar acters
Theygr ow readi
lyonmostoft hebact er i
ologi
calmedia. Temper aturer ange10–42oC
(Optimum 37oC) .pHr ange7.4–7. 6.
Theyar eaer obesandf acultativeanaerobes.OnNA–1. 4mm di amet ercoloniesappear.
Theyar ecircular
,conv ex,smoot h,shiny,opaqueandeasi lyemulsifi
able.
Theypr oduceadeepgol deny ell
ow colonywhi chdoesnotdi f
fusei nt
ot hemedi um.On
nutri
entagarsl ant,theirgrowt hpr esent s“oilpai nt”appear
ancei ndi
catesconf luentgr owthofS.
aureus.
On blood agarpl ates,col oniesofSt aphy l
ococcusaureusar efrequentlysur rounded by
zonesofcl earβ-Haemol y
ticcoloniesar eproduced.
Thegol denappear anceofcol oniesincubat edwith20–25%CO2onr abbi
torsheepbl ood.

18
 OnMacconkey ’
smedi um smal lpinkl actosef erment i
ngLFcol oniesappear .I nliquidmedi a
unifor mt ur bidityi sobser v ed.
3.Biochemi calReact i
ons
Allt hesugar swer ef erment edpr oduci ngaci dbutnogas.Theyar eanaer ogenic.Gl ucose,l act
ose,
manni t
ol f erment edwasobser vedandt hebact eriawasnonmot il
e.
Theyar eCat alase, Ur ease, DNAse, Phosphat ase, Coagul ase, MRandVP+v ebuti ndol e–v e.OnTSI ,
glucose, sucr ose, lactoseandmani tolwer eferment edr esulti
ngi nacidsl antandbut t(A/ A).Thistest
different iat esS.aur eusf rom epi dermi dis,β-hemol ysisonbl oodagar .
4.Resi st ance
Thesear emor er esi stantofnonspor ingbact eria.Theyr etainv i
abilit
yupt on3-6mont hswhendr i
ed.
o o
Theymaywi t hst and60Cf or30mi n.Toki llthem 80Ct emper aturef or1hri sr equi red.Theyar e
resist antt o1%phenol (15mi n) ,Mer cur i
cperchl oride( 1%f or10mi n)andl ysozyme.
Sensi ti
v et o Peni cil
lin or i
ginally butsome st rai
ns hav e dev eloped r esi
stance by pr oducing
peni cilli
nase.
5.TOXI NSANDVI RULENCEFACTORS
Cy t
ol ytict oxins Haemol ysin
Leucoci dins
Enter ot oxi n
Exfol iativet oxin
Coagul ase
Haemol ysinsAl pha
Bet a
Gamma
Del ta
Toxi cShockSy ndr omeToxi n(TSST)
Itisr esponsi bl ef orToxi cShockSy ndr ome( TSS)
Theybel ongt ophagegr oupI
Italsoknownt opy rogeni cexot oxinC.
6.Pat hogeni cit
y
 St aphy l
ococciar ef oundasnor malf loramember s.Theyar ealsof oundoncl othing,beds,
skinet c.
 Itmayent eri ntobodyt hroughwoundsornasophar ynxormaycausei nfect i
onswhen
i
mmuni tyofapat i
enti sl ostt houghi tst ay sasanor mal fl
or amember .
 St aphy l
ococci causet hemaj orityofacut epy ogeni clesi
onsi nman.
 St aphy l
ococcaldi seases maybe cut aneous ordeep i nfecti
on orf ood poi sonings or
exfol i
at ivedi seasesandt oxi cshocksy ndr ome.
 Cut aneousi nfect ions
 Deepi nf ections
 Tox i
nmedi ateddi seases
 Tox i
nmedi ateddi seases
 Foodpoi soni ng
 Ski nseal di
ngsy ndr ome
 TSS
 1.Cut ancousi nfect ionsi ncl udet urunel es,styes, boil
s,absceases, car
buncl es, impetigoand

19
 phenphi gusheonat or um.I tal socausessepsi si nwoundsandbur ns.
 2.Deepi nfect ions:
 Act ue ost eomy el
itist onsill
it i
s,phar yngi ti
s,si nusi t
is,pneumoni a br eastabscesses i n
l
act at i
ngmot her ssept icemi ameni ngitis,endocar diti
s,r enalabscesst r
opicalpy omy ositi
s–mul t
iple
abscessesi nv oluntar ymuscl es.
3.FoodPoi soni ng
FoodPoi soni ngi sduet oent er otoxinpr oducingst rainsofSt aphaureus.
Ty pesoff oodr esponsi blear emeat ,f i
sh,mi l
kandmi l
kpr oducts.
Modeofi nfect i
on :Consumi ngf oodcont ami nat edwi thenter
otoxi
npr oducingSt aphaureus
I
ncubat ionper iod :6hr s
Sympt oms: Nausea, v omi ti
ng, diarrhea
7.LagDi agnosi s:
Pus- from abscesses, wounds, bur ns
Sput um- respi ratoryt r
acti nfect i
ons
Faccesorv oimi t
-from casesoff oodpoi soning
Blood - bact eremi a
Mi dst ream ur ine-f rom pat ient swi thsuspect edcy stitis,
Py elonephr itis,post -cat het erizationi nfect i
on.
Ant er i
ornasal andper ianal swabs-f rom car ri
er s
Gram st ainshowst hepr esenceofGPCi ncluster s.
Cul turemedi ausedar ebl oodagar ,manni tolsaltagar
Ident ificationofSt aphy locci :
Cat alasedi ffer entiatesSt aph, from St r eptococci .St aph.Cat al
ase-Posit
ive
St r
ep.Cat alase-Negat ive
8.Epi demi ology
Theyar epar asitesofhumanbei ngsandani mal s.
Theyar epr esentasnor mal floraofnose.
Sour cesofi nf ect i
onsar ehuman, pat i
ent sandcar ri
er s,animal s,i
nani
mat eobjects.
Modeoft r
ansmi ssion:Cont act ,
di r
ectort hroughf omi tes,bydustorbyai rbornedr opl
et s.
9.Treat ment
Asdr ugr esist ancei sacommonamongst aphy l
ococci ,butbasedonant ibi
ot i
csensi t
ivi
tyt
ests,
ant i
bi oticsar echosen.
Benzy lpeni cilli
ni st hemostef fectiveant i
biot i
c. Met hicill
i
nandcl oxacill
inar eef fect
ivetotreat
peni cilli
nr esi stantst rai ns.
1.STREPTOCOCCUS

I
NTRODUCTI
ON:

Theyar
egr
am +i
vecocci
arr
angedi
nchai
norpai
rs.

CLASSI
FICATI
ON:

BasedonO2r
equi
rement

20
 AnaerobesStr
eptococci Facul
tat
iv obesSt
eAnaer rep
Peptost
rept
ococci
BasedonHaemol
ysi
s
Patt
ernonbl
oodagar

-
haemol
ytcSt
i rep -
haemol
ytcSt
i rep 
-haemol
ytcSt
i rep

(
1)I
ncompl
etehaemol
ysi
s (
1)NochangeonBA
(
2)Occurascommensal
oft
hroat 2)Ent
( erococcusgr
oup

BasedonCar
bohy
drat
eAg
19Lancef
iel
dgr
oupA–U(
exceptI&J)

oupA–St
Gr rept
ococcuspy
ogenes

Basedon‘
M’pr
otei
n

80r
if
fi
tht
ypes

2.STREPTOCOCCUSPNEUMONI
AE
St
rept
ococcuspneumoni
acommonl
ycal
l
edt
hepneumococcuswasi
sol
atedi
n
1881 by Past
eur oduced a Fat
.They pr alSept
icaemi
ain Rabbi
ts and i
tcauses
Pneumoni
ainhumanbei
ngs.
Pneumococciar
egr
am +v
e,l
anceol
atedi
plococci
cwhi
chr
esembl
ethev
iri
dians
st
rept
ococcibutt
hepneumoccoushasbeenr
ecl
assi
fi
edasSt
rept
ococcuspneumoni
a
becauseofi
tsgenet
icr
elat
ednesst
oSt
rept
ococcus.
Mor
phol
ogy
:
Pneumococci
aret
ypi
cal
l
ysmal
l(1)sl
i
ght
lyel
ongat
edcocci
,wi
thoneendbr
oad
andot
herpoi
nted,pr
esent
ingaf
lameshapedorl
anceol
ateappear
anceGr
am (
+iv
e)

21
cocciwhi
char
elanceol
ateshaped–oneendbr
oadandot
herendpoi
nted.Theyoccur
i
npai
rs,wi
thbr
oadendsi
nopposi
ti
on.Theyar
ecapsul
ated.Capsul
eencl
osi
ngeach
pai
r.Capsul
esar
elostbyr
epeat
edsubcul
tur
es.Theyar
enon-
mot
il
eandnon-
spor
ing.

Cul
tur
alChar
act
eri
sti
cs:
Theyoccurbestwi
th5-
10%CO2.
o
Opt
imum t
emper
atur
e:37C.
Theyar
efast
idi
ous.
OnBA:Af
ter18hr
scol
oni
esar
esmal
l
,domeshaped,gl
i
steni
ngwi
thgr
eeni
sh
di
scol
our
ati
on(
-haemol
ysi
s).
Af
ter24hr
scol
oni
esbecomef
latwi
thr
aisededgesandcent
ralumbonat
ion
(
Car
rom coi
nappear
ance)
.Capsul
atedst
rai
nspr
oducemucoi
dcol
oni
es.
I
nbr
othcul
tur
esuni
for
mtur
bidi
tyi
sobt
ained.Coccir
eadi
l
yunder
goaut
oly
sis
duet
oact
ivi
tyofaut
oly
ticenzy
mes.
Bi
ochemi
calReact
ions:
1) CHOf
erment
ati
ont
est
sdonei
nHi
ssser
um sugar
s.
Gl
ucose,
lact
ose,
sucr
ose,
inul
i
nfer
ment
edwi
thaci
d.
2)Bi
l
esol
ubl
i
tyt
est
:Pneumococcusar
esol
ubl
einbi
l
e.
ANTI
GENI
CPROPERTI
ES:
(
1) Ty
pespeci
fi
ccapsul
arpol
ysacchar
ides.
- I
tisal
socal
l
edSpeci
fi
csol
ubl
eSubt
ance(
SSS)si
ncei
tdi
ff
usesi
ntot
hecul
tur
e
medi
um ort
issuesorexudat
es.
- Basedoncapsul
arpol
ysacchar
ideant
igeni
cnat
ure;85di
ff
erentser
oty
pesar
e
nowr
ecogni
sed.
- I
tisant
igeni
c.
- I
tisant
iphagocy
tic.
- Vi
rul
encei
srel
atedt
othedegr
eeofcapsul
arpol
ysacchar
ide.Ty
pe3i
smost
v
irui
entbecauseoft
heabundanceofi
tscapsul
armat
eri
al.
- Abt
ocapsul
arpol
ysacchar
ideaf
for
dspr
otect
ionagai
nsti
nfect
ion.
(
2)Nul
ceopr
otei
nant
igenand‘
C’CHO.Ag.Bot
hofwhi
char
especi
esspeci
fi
c.Abt
o
t
heseAgar
enotpr
otect
ive.

22
 (
3)Li
pot
eichoi
caci
dFor
ssmanAg.
Pat
hogeni
cit
y:
1.LOBARPNEUMONI
A:
- Pneumococcii
nthr
oatar
eei
thercl
i
minat
edbynat
uraldef
encemechani
sm or
t
heyest
abl
i
shsy
mpt
oml
esscar
ri
agei
nthet
hroat
.Pneumoni
aoccur
sonl
ywhen
i
nsuchacar
ri
er,gener
alr
esi
stancei
sl ed. Pneumococcipenet
ower rat
ethe
br
onchi
almucosaandspr
eadt
hrought
hel
ungal
ongt
heper
ibr
onchi
alt
issues
andl
ymphat
ies.Bact
eremi
aisf
requentdur
ingt
heear
lst
ageofpneumoni
a.
- I
nadul
tst
ypes1-
8ar
eresponsi
blef
orabout75%ofcases.I
nchi
l
dren,t
ypes6,
14,
19and23ar
efr
equentcauses.
2.BRONCHOPNEUMONI
A:
- I
tisasecondar
yinf
ect
ionandf
oll
owsv
iral
inf
ect
ionofr
espi
rat
oryt
ract
.
- Causedbyanyser
otpeofPneumococci
y .
- Damaget
orespi
rat
oryepi
thel
i
um andexcessbr
onchi
alsecr
eti
onscausedby
pr
imar
yinf
ect
ionf
aci
l
itat
einv onofPncumococci
asi alongt
hebr
onchi
alt
ree.
3.MENI
NGI
TIS:
- I
tist
hemostser
iousofpneumococcali
nfect
ions. I
tissecondar
ytoot
her
pneumococcal i
nfect
ions such as pneumoni
a,ot
it
is medi
a,si
nusi
ti
s or
conj
unct
ivi
ti
s.
- I
toccur
sinal
lages.
- I
funt
reat
edt
heyar
einv
ari
abl
yfat
al.
- LABORATORYDI
AGONOSI
S:
- Speci
mens:
- I
ncaseofpneumoni
a- Sput
um,
Blood
- I
ncaseofmeni
ngi
ti
s- C.
S.F.
,Bl
ood
- DI
RECTMI
CROSCOPY:
- Gr
am St
ain:
- Pr
esenceofGr
am posi
ti
vel
anceol
atecoccii
npai
rswhi
char
ecapsul
ated
i
nC.
S.F.i
sapr
obabl
edi
agnosi
sofpneumonococcal
meni
ngi
ti
s.
- Conf
ir
mat
ion can be done bydoi
ng coaggl
uti
nat
ion t
estwi
th pool
ed
ant
iser
aandt
henwi
thmonov
alentant
iser
atopneumococcal
ser
oty
pes.

23
 - Lat
exAggl
uti
nat
iont
esti
sal
soav
ail
abl
etodet
ectt
heser
oty
pes.
Pr
ophy
laxi
s:
I
mmuni
tyi
sty
pe speci
fi
c and associ
ated wi
th ant
ibody t
othe capsul
ar
pol
ysacchar
ide. Theexi
stenceofmor
ethan85ser
oty
peswoul
dseem t
omake
pr
ophy
lact
ici
mmuni
sat
ioni
mpr
act
icabl
e.Butasmostpneumoni
acasesar
ecaused
by a l
i
mit
ed number of ser
oty
pes. Vacci
nat
ion i
s possi
ble. I
n 1983,a
pol
ysacchar
idev
acci
necont
aini
ng23t
ypeswasl
i
censedi
nU.
S.A.suchv
acci
nesar
e
usedspeci
all
yinchi
l
drenwhoar
eabov
e2y
ear
sofage.
Tr
eat
ment
:
Amoxy
cil
l
in,
Sul
fonami
desandpenci
l
li
nsar
equi
etef
fect
ivedr
ugs.

3.GROUPASTREPTOCOCCUSPYOGENES
STREPTOCOCCUSPYOGENES
MORPHOLOGY:
Gr
am posi
ti
vespher
ical
cocci
arr
angedi
nchai
ns,
theyar
enon-
mot
il
e,non-
spor
ingandcapsul
ated.
CULTURALCHARACTERS:
- Facul
tat
iveanaer
obes.
- Opt
imum t
emper
at e37oC
ur
- Fast
idi
ousdonotgr
owonNAorgr
owsonl
ypoor
ly
- OnBAi
tpr
oduces-
haemol
yti
ccol
oni
eswhi
char
esmal
l
,ci
rcul
ar,
transpar
ent
l
owconv
ex.Haemol
ysi
senhancedby5–10%CO2.
- Thosewi
thwel
lpar
kedcapsul
espr
oducemucoi
dcol
oni
es
- Sel
ect
ivemedi
aiscr
yst
alv
iol
etbl
oodagar
.

- I
nli
qui
dmedi
agr
owt
hoccur
sasgr
anul
art
urbi
dit
ywi
thpowder
ydeposi
t.

BI
OCHEMI
CALREACTI
ONS:

- Theyf
ermentsugar
s(l
act
ose,
mal
tose,
dext
ri
nmanni
tol
,sor
bit
ol,
trehal
oge)wi
th
aci
d,nogas

- Theyar
ecat
alase–(
ive)

24
AgofSt
rept
ococci
:
5)Capsul
eisnotant
igeni
c,i
tinhi
bit
sphagocy
tosi
s
6)Out
erl
ayeroff
imbr
iacont
aini
ngpr
otei
nandl
i
pot
eichoi
caci
d.
7)Gr
oupspeci
fi
cC.Car
bohy
drat
eAg.
- I
tisani
ntegr
alpar
tofcel
lwal
l
.
8)Pr
otei
nAgpr
esentoncel
lwal
lar
eM,
T,R,
‘M’
prot
eini
smosti
mpor
tantoft
hese
andhel
psi
nat
t entofSt
acheni rept
ococcit
ohostcel
l
s.
- I
tact
sasv
irul
encef
act
orbyi
nhi
bit
ingphagocy
tosi
s.
- I
tisant
igeni
candant
ibodi
est
o‘M’
prot
einpr
omot
ephagocy
tosi
s.(
Ther
efor
e
pr
otect
ive)
- I
tisheatandaci
dst
abl
e.

PATHOGENESI
S
Di
seasespr
oducedar
e
(
7)Respi
rat
oryi
nfect
ion Phar
yngi
ti
s
Tonsi
l
li
ti
s
(
8)Ski
ninf
ect
ions
(
9)Subcut
aneousi
nfect
ions
(
10) Geni
tal
inf
ect
ions
(
11) Suppur
ati
vei
nfect
ions
(
12) PostSt
rept
ococcalsequel
aeornon-
suppur
ati
vecompl
i
cat
ions
(
1)Sor
eThr
oat
:
 I
ti hecommonestSt
st rept
ococcaldi
sease
 Whenl
ocal
i
sedi
scal
l
edt
onsi
l
li
ti
s,i
scommoneri
nol
derchi
l
drenandadul
tst
hani
n
y
oungerchi
l
dren.
 Sor
ethr
oatmayi
nvol
vephar
ynxmor
edi
ff
usel
ytocausephar
yngi
ti
s.
 St
rept
ococciat
tachesbymeansofi
tsl
i
pot
eichoi
caci
dcov
eri
ngt
hesur
facepi
l
i.
Theyat
tacht
hemsel
vest
ogl
ycopr
otei
nrecept
orsont
her
espi
rat
oryepi
thel
i
alcel
l
s.

Compl
icat
ionsofSor
eThr
oat
:

25
 Fr
om t
hroat
,theycanspr
eadt
osur
roundi
ngt
issuesl
eadi
ngt
oot
it
ismedi
a,
mast
oidi
ti
s suppur
ati
ve adeni
ti
s. St
rept
ococcal pneumoni
a may occur as a
compl
i
cat
ionofi
nfl
uenzaorot
herr
espi
rat
oryv
iral
inf
ect
ions.
SKI
NINFECTI
ONS:
a)I
mpet
igo:St
rept
ococcit
hatcausei
mpet
igoar
eder
ivedmai
nlyf
rom ski
nlesi
onson
ot
herper
sons.
b)Er
ysi
pel
as:
- I
tisr
arert
hani
mpet
igo,
aff
ect
susual
l
yel
der
ly.
- I
nfect
edar
easshowedemaander
ythema.
- I
tmaybeduet
ohy
per
sensi
ti
vi
tyofper oSt
sont rept
ococcalpr
oduct
s.
Subcut
aneousI
nfect
ion:
- Somest
r nsofSt
ai rep.Py
ognenesi
.eM t
ypeIst
rai
nsf
ormi
ngpy
rogeni
cex
otoxi
n
Acont
ri
but
etonecr
oti
singf
asci
i
tis.
Puer
per
alSepsi
s:Si
ncet
heyoccurasnor
mali
nhabi
tansoff
emal
egeni
talt
ract
,
t
heycausedpuer
per
alsepsi
sorchi
l
dbedf
everwhi
cht
ookheav
ytoi
lofl
i
fedur
ing
pr
eant
ibi
oti
cer
a.
Suppur
ati
vei
nfect
ions:Theymaycausesabcessesi
nint
ernalor
ganssuchas
br
ain,
lung,
li
ver
,ki
dneyandal
sosept
icemi
a.
Nonsuppur
ati
vecompl
i
cat
ionsar
eRFandAGN.
Rheumat
icFev
er(
RF)
:
Anat
tackofRFi
srel
atedt ecedentSt
oant rept
ococcalt
hroati
nfect
ionoccur
ri
ng1-
5
wks ear
li
er.Suppor
tfor t
his associ
ati
on i
s based on cl
i
nical
,bact
eri
ologi
cal
,
epi
demi
ologi
cal
,ser
ologi
cal
andchemopr
ophy
lact
icev
idence.

EPI
DEMI
OLOGY:
- Sour
ceofi
nfect
ion–Pat
ient
sandcar
ri
ers.St
rept
ococciar
ecar
ri
edi
nthet
hroat
,
nasophar
ynxandnose.
- Sy
mpt
oml
essi
nfect
ioni
scommon.
ModeofTr
ansmi
ssi
on:
d)Di
rectcont
act
e)Cont
ami
nat
eddust

26
 f
) Thr
oughf
omi
tes
Ov
ercr
owdi
ngf
avour
str
ansmi
ssi
onofi
nfect
ion
LABORATORYDI
AGNOSI
S:
Acut
eInf
ect
ion - Di
agnosi
sest
abl
i
shedbycul
tur
e
Nonsuppur
ati
vecompl
i
cai
tons- Di
agnosi
sisbasedondemoofAbt
o
St
rept
ococcalAg
Speci
mens:
5)Thr
oatswab
6)Swabsf
rom ski
nlesi
ons
7)CSF
8)Ser
um f
ordet
ect
ionofAb
PRESUMPTI
VEDI
AGNOSI
S:
Pr
esenceofGPCi
nchai
nsi
npusandCSFi
sindi
cat
iveofSt
rept
ococcali
nfect
ion.
Buti
tisofnov
aluei
nthr
oatswabwher
etheor
gani
smsf
orm apar
tofnor
mal
flor
a.
MEDI
AUSEDFORCULTURE:
Cr
yst
alv
iol
etbl
ood agari
sasel
ect
ivemedi
um. Af
terpl
ati
ng i
tshoul
d be
i edat37oCunder5-
ncubat 10%CO2.
Col
onyMor
phol
ogy
:
-haemol
yti
csmal
ltr
ansl
ucentcol
oni
es.
St
rept
ococcalGr
oupi
ngcanbedoneby
Mi
croni
tr
ousaci
dext
ract
ionmet
hod
Lancef
iedhotaci
dext
ract
ionmet
hod
oupASt
Gr rept
ococciar
euni
for
mlysuscept
ibl
etobaci
tr
aci
n.
SEROLOGI
CALTESTS:
Ant
i-
Str
ept
oly
sinO (
ASO)det
ect
ionar
edonebyCA orbymi
crot
it
remet
hod
usi
ngr
abbi
tRBC.Ti
tr
eabov
e240I
Uinchi
l
drenand340I
U’nadul
tsar
esi
gni
fi
cantof
postSt
rept
ococcalsequel
ae.
Ant
iDNAseB:Ti
tr
eabov
e800I
Uar
esi
gni
fi
cant
.
Ant
ihy
alur
oni
dase:A-DNAaseBandant
ihy
alur
oni
daset
est
sar
ever
yusef
ulf
or
r
etr
ospect
ivedi sofSt
agnosi rept
ococcalr
einf
ect
ionandf
urt
herdamaget
ohear
t.
TREATMENT:
Peni
cil
l
ini
sthedr
ugofchoi
ce(
ifal
l
ergi
c)Er
ythr
omy
cinorCephal
exi
nar
eused.

27
 4.BACI
LLUSANTHRAX
I
NTRODUCTI
ON:
I
tisazoonot
icdi
seasepr
imar
il
yrecogni
zedi
nlar
gedomest
icat
edani
mal
swhi
ch
i
nfect
smanacci
dent
lyt
hroughcont
actwi
thi
nfect
edpr
oduct
s.
Mor
phol
ogy
Baci
l
lusant
hraci
sisaGr
am –posi
ti
ve,l
arge(
4.8x1–1.
5m)squar
e–ended
(
rect
angul
ar)
,st
rai
ghtspor
ingbaci
l
li
. Thespor
esar
eref
ract
il
e,ov
alandcent
rali
n
posi
ti
on and i
ts di
amet
eri
s same as t
he wi
dth oft
he baci
l
lus. The baci
l
liar
e
encapsul
ated,nonmot
il
e,ar
rangedsi
ngl
yori
nshor
tchai
ns.Theent
ir
echai
nmaybe
sur
roundedbycapsul
ewhi
chi
spol
ypept
idei
nnat
ure(
D-gl
utami
caci
d).
I
nti
ssues,
spor
e–f
ormsar
enev
erf
oundandt
hebact
eri
aoccursi
ngl
yori
npai
rs.
SOURCESOFI
NFECTI
ON:
1.Spor
espr
esenti
nsoi
l
.
2.I
nfect
eddomest
icani
mal
s.

MODEOFI
NFECTI
ONS:
(
1)Cut
aneousAnt
hrax- I
nocul
ati
ont
hrought
heski
noft
hemat
eri
alf
rom
I
nfect
edani
mal
sort
hei
rpr
oduct
s.
(
2)Pul
monar
yAnt
hrax- I
nhal
ati
onofspor
esi
ndustorwool
fibr
es.
(
3)I
ntest
inal
Ant
hrax - Eat
ingcar
cassesofdeadani
mal
s.
EPI
DEMI
OLOGYOFANTHRAX:
- I
tisazoonosi
s–adi
seasei
fani
mal
str
ansmi
ssi
blet
ohumans.
- Ani
mal
sar
einf
ect
edbyi
ngest
ionofspor
espr
esenti
nthesoi
l
. Spr
eadf
rom
ani
malt
oani
malar
erar
e,i
nfect
edani
mal
sshedl
argenumberofbaci
l
lif
rom
mout
h,noseandr
ect
um.Thesebaci
l
lispor
ulat
einsoi
landr
emai
nasasour
ce
ofi
nfect
iont
oman.
- Humanant
hraxi
scont
ract
edf
rom ani
mal
sdi
rect
lyori
ndi
rect
ly.
- Spor
esoft
hisbaci
l
lusar
ehi
ghl
yresi
stantt
ophy
sical
andchemi
cal
agent
s.
- Theysur
viv
einsoi
lasl
ongas60y
ear
s.
PATHOGENESI
S:
Humanant
hraxi
scont
ract
edf
rom ani
mal
s,di
rect
lyori
ndi
rect
ly.

28
 - Di
seasemaybe(
1)Cut
aneous(
2)Pul
monar
y(3)I
ntest
inal
- Cut
aneousant
hraxf
oll
owsent
ryoft
hei
nfect
iont
hroughski
n,f
ace,
neck,
arms
andbackar
etheusual
sit
es.
- Lesi
onst
art
saspapul
e1-
3day
saf
teri
nfect
ionandbecomesv
esi
cul
ar
cont
aini
ngbl
oodst
ainedorcl
earf
lui
d.
- Lesi
onunder
goescent
ral
necr
osi
scov
eredbyabl
ackeschar
,sev
eral
sat
ell
i
te
l
esi
onsappearsur
roundi
ngt
hecent
ral
oneandt
hewhol
ear
eai
scal
l
eda
mal
i
gnantpust
ule.
- Cal
l
edashi
depor
ter
’sdi
seasesi
ncei
scommonamongdockwor
ker
scar
ryi
ng
hi
desandski
nont
hei
rbar
ebacks.
- I
tresol
vesspont
aneousl
ybut10-
20%ofunt
reat
edpat
ient
sdev
elopf
atal
sept
icemi
aandmeni
ngi
ti
s.
PULMONARYANTHRAX:
- Cal
l
edwool
sor
ter
sdi
seasesi
ncei
tiscommoni
nwool
fact
orywor
ker
s,duet
o
i
nhal
ati
onofdustf
rom i
nfect
edwool
.
- Ther
eishemor
rhagi
cpneumoni
awi
thahi
ghf
atal
i
tyr
ate.
- Meni
ngi
ti
soccur
sascompl
i
cat
ion.
I
NTESTI
NALANTHRAX:
- I
tisr
areandoccur
sinpr
imi
ti
vecommuni
ti
eswhoeatcar
cassesofani
mal
s
dy
ingofant
hrax.
- Bl
oodydi
arr
hocawi
thhi
ghcasef
atal
i
tyseen.
I
NDUSTRI
ALANTHRAX:
Foundi
nwor
ker
sini
ndust
ri
essuchasmeatpacker
sorwool
fact
ori
es.
NONI
NDUSTRI
ALANTHRAX:
Seeni
nfar
mer
s,but
cher
s,v
eter
inar
iansandi
ngener
alpopul
ati
on.
LABORATORYDI
AGNOSI
S:
i
. Di
rectMi
croscopy
i
i
. Cul
tur
e
i
i
i. Ani
mal
Inocul
ati
on
i
v. Demonst
rat
ionofAnt
hraxant
igeni
ninf
ect
edt
issues
v
. Ser
ology

29
SPECI
MENS:
- Cut
aneousAnt
hrax- Fl
uidAspi
rat
edf
rom unbr
okenl
esi
on
- Pul
monar
yAnt
hrax- Sput
um
- Ant
hraxMeni
ngi
ti
s- C.
S.F.
- I
ntest
inal
Ant
hrax - Faeces
Saf
ety
:Gr
eatcar
eshoul
dbet
akent
oav
oidescapeofl
ongsur
viv
ingspor
esi
ntot
he
l
abor
ator
yenv
ironmentandpr
ocessi
ngofspeci
menshoul
dbedonei
nsi
deacat
egor
y-3
exhaustv
ent
il
atedsaf
etycabi
net
.
Gr
am St
ainoft
heDi
rectSmear
:
- Gr
am posi
ti
vebaci
l
liwi
thpar
all
elsi
desandsquar
eendsar
rangedsi
ngl
y,pai
rs,
or
i
nshor
tchai
ns.
- Theyar
esur
roundedbycapsul
e.
- Spor
esabsenti
ndi
rectsmear
.
CULTUREMEDI
Ausedar
e
(
1)Bl
oodAgar
(
2)Pol
ymy
xin,
Lysozy
me,
EDTAandThal
l
usacct
ateagar(
PLET)i
sasel
ect
ivemedi
a
t
hismedi
um i
nhi
bit
sthegr hofB.Cer
owt eus,B.Subt
il
isot
herbaci
l
lusspeci
es
ent
erobact
eraceaeandPseudomonas.
i
CULTURALMORPHOLOGY:
- OnBAcol
oni
esar
enon-
haemol
yti
c,gr
eyi
shwhi
te,dul
l
,ir
regul
arwi
thaf
rost
ed
gl
assappear
ance.
PROPHYLAXI
S:
- Car
cassesofani
maldy
ingofant
hraxshoul
dbebur
ri
esdeepi
nqui
ckl
i
meor
cr
emat
edt
opr
eventsoi
lcont
ami
nat
ion.
- Ducker
ingi
sthepr
ocessbywhi
chspor
esar
edest
roy
edf
rom wool
andhi
de.
ForWool - 2%HCHOat30o–40oCf
or20o.
Ani
mal
Hai
r - 25%HCHOat60oCf
0. or6hr
s.
PREVENTI
ONOFANTHRAXI
NANI
MALS:
(
1)Past
ure’
sVacci
ne - Ant
hraxbaci
l
liat
tenuat
ed bygr h at42o-
owt
43oC.
(
2)St
erneVacci
ne - Spor
esofnoncapsul
atedav
irul
entmut
antst
rai
ns

30
 ar
eused.
(
3)Mazucchi
Vacci
ne - Spor
esofat
tenuat
edcar
bazoost
rai
nar
eused.
VACCI
NEFORHUMANUSE:
- Al
um pr
eci
pit
atedt
oxoi
dpr
epar
edf
rom pr
otect
iveAghasbeenusef
ulonl
yby
per
sonsoccupat
ional
l
yexposedt
obaci
l
li
.
- 3dosesgi
venI
M ati
nter
val ween1stand2nd and6mont
sof6weeksbet hs
nd r
d
bet
ween2 and3 wi
thannual
boost
ers.
TREATMENT:
Peni
cil
l
ini
sthedr
ugofchoi
ce.

5.CLOSTRI
DIUM TETANI

Mor
phol
ogy
:Iti
sasl
ender
,longsl
i
ght
lycur
ved,
Gram posi
ti
ve,
2–5x0.
4–0.
5
m baci
l
luswi
tht
ermi
nalspor
ewi
thchar
act
eri
sti
cdr
umst
ickappear
anceandmat
ch
st
ickappear
ance.Theyar
emot
il
ewi
thper
it
ri
chousf
lagel
l
aandnoncapsul
ated.
Cul
tur
alChar
act
ers:Theyar
eobl
i
gat
oryanaer
obesduet
othei
rinabi
l
ityt
out
il
ize
oxy
genasf
inalhy
drogenaccept
or. Theor
gani
smsgr
ow i
nor
dinar
y(nut
ri
entagar
)
medi
aandgr
owt
hispr
omot
edbyaddi
ngbl
oodandser
um.Thebaci
l
lipr
oduceat
hin
spr
eadi
ng f
il
m i
n bl
ood agar
. Theyf
orm smal
lhaemol
yti
c(
haemol
ysi
s -
haemol
ysi
s)col
oni
esi
nhor
sebl
oodagarduet
opr
oduct
ionofheamol
ysi
n(t
etanol
ysi
n).
I
ngel
ati
nst
abcul
tur
esaf
irt
reet
ypeofgr
owt
hoccur
swi
thgel
ati
nli
qui
fact
ion.
Occur
rence:Cl
.Tet
anii
swi
del
ydi
str
ibut
edi
nsoi
landi
nthet
est
sofhuman
bei
ngsandani
mal
s.I
tisubi
qui
tousf
oundi
nchest
,wound,
clot
hinget
c.
Bi
ochemi
calReact
ions:Cl
.Tet
anii
ssl
i
ght
lypr
oteol
yti
canddoesnotf
ermentany
sugar
.Itdoesnotf
orm H2S andMR,VP negat
ive. I
tfor
msi
ndol
e. A gr
eeni
sh
f
luor
escencei
spr
oducedonmedi
acont
aini
ngneut
ral
redasi
nMacconkey
’
Cl
assi
fi
cat
ion:Based on aggl
uti
nat
ion r
eact
ion 10 ser
ologi
calt
ypeshav
ebeen
r
ecogni
sedi
nCl
.Tet
ani
.Theyar
ety
pes1–10.Al
ltheset
ypespr
oducet
hesev
ere
t
oxi
nswhi
chi
sneut
ral
i
zedbyanant
it
oxi
nspr
oducedagai
nstanyt
ype.
Ant
igen:Al
lst
rai
nsshar
eacommonsomat
ic(
O)ant
igenont
hebasi
soft
ype

31
speci
fi
cfl
agel
l
ar(
H)ant
igens,
10t
ypes(
I–X)ar
erecogni
sed.
Toxi
ns:Toxi
nspr
oduct
ionappear
stobepl
asmi
dmedi
ated.Exot
oxi
nofCl
.Tet
ani
hasgotatl
east2component
s.
1.Hemol
ysi
n(Tet
anol
ysi
n)
2.Tet
anospasmi
n(Power
ful
neur
otoxi
n)
1.Tet
atol
ysi
n:I
tisheatandoxy
genl
abi
l
eandcausesl
ysi
sofr
edbl
oodcel
l
sof
manyspeci
es,especi
all
ythoseofr
abbi
tandhor
se.I
tspat
hogeni
crol
eisnotcl
ear
.It
mayactasl
eucoci
din.
2.Tet
anospasmi
n:I
tisaneur
otoxi
n,oxy
genst
abl
eandheatl
abi
l
einact
ivat
edat
o
65Ci
n5mi
nut
es.I
tisl
ethalt
omi
ceandgui
neapi
gsi
nmi
nut
edose(
Let
haldosef
or
mouse0.
0000001mg)andt
heydi
ewi
thi
n1t
o2day
saf
teri
nject
ionoft
etanospasmi
n
wi
tht
ypi
calsi
gnsoft
etanus.Tet
anospasmi
nisagoodant
igenandget
sneut
ral
i
zedby
ant
it
oxi
n.Thi
sneur
otoxi
ncausescl
i
nical
mani
fest
ati
onsoft
etanus.

Pat
hogeneci
ty:
I
nfect
ionwi
thCl
.Tet
anii
sacqui
redbyt
hei
mpl
ant
ati
on(
or)i
nocul
ati
onoft
he
spor
esofCl
.Tet
ani
ont
hesur
faceoft
hewounds.Cl
.Tet
ani
hasl
i
ttl
einv
asi
vepower
.
Thet
oxi
nhasadi
rectef
fectoncent
ralner
voussy
stem. Veget
ati
vebact
eri
a
ger
minat
eunderf
avour
abl
eanaer
obcondi
ti
onsf
rom spor
esi
mpl
ant
edi
nawoundand
mul
ti
plyl
ocal
l
y.Cl
.Tet
anidoesnotspr
eadbey
ondt
hewound.Toxi
npr
oducedbyt
he
bact
eri
aisabsor
bedbymot
orner
veendi
ngwhi
cht
rav
elsal
ongt
hemot
orneur
onsof
per
ipher
alner
vet
otheant
eri
orhor
ncel
l
soft
her
elev
antpar
toft
hebr
ainst
em orspi
nal
cor
dcont
aini
ngneur
onesoft
heaf
fect
edner
vesandt
hisl
eadst
o“Localt
etanus”i
nthe
pr
oxi
mit
yoft
hewound. Thent
het
oxi
nspr
eadsupwar
dst
owar
dsC.
N.S.al
ongt
he
spi
nalcor
dandpr
oduces“
ascendi
ngt
etanus”(
Gener
ali
sedspasm)
.Howev
er,i
fthe
t
oxi
nisi
nject
edi
ntr
avenousl
yspasm appear
sfi
rsti
nthemuscl
esofheadandneckand
t
hen spr
eads downwar
ds – “
descendi
ng t
etanus”whi
ch r
esembl
es t
he nat
ural
l
y
occur
ri
ngt
etanus.
Thet
oxi
nisspeci
fi
cal
l
yfi
xedt
othegangl
i
osi
desi
nthegr
eymat
terofspi
nalcor
d
andbr
ainst
em.I
tact
satsy
napt
icj
unct
ionsbet
weenant
eri
orhor
ncel
l
sandr
elat
ed
i
nter
nuni
calneur
ones. Thet
oxi
ntakeni
ntoner
vesbyendocy
tosi
sandi
scar
ri
edby

32
cy
topl
asm t
otheCNSandbl
ocki
ngt
her
eleaseofcer
tai
ninhi
bit
orychemi
cal
satt
he
spi
nalcor
d. Thei
ncubat
ionper
iodi
svar
iabl
efr
om 2day
stosev
eralweeksbuti
s
commonl
y6– 12day
s. Thi
sisi
nfl
uencedbysev
eralf
act
orssuchast
hesi
teand
nat
ureoft
hewoundandt
oxi
geni
cit
yoft
hecont
ami
nat
ingor
gani
sms,
doseofi
nfect
ion
andt
hei
mmunest
atusoft
hepat
ient
.
I
nfi
rstsy
mpt
omsoft
hedi
seasei
s‘t
ri
smus’char
act
eri
zedbypai
nfulspasmsof
t
hej
awmuscl
eswhi
chkeepst
hej
awst
ight
lycl
osed.Hencet
etanusi
sal
soknownas
“
LockJaw”di
sease(
ri
sussar
dor
icus)
.
I
tbegi
nswi
thr
est
lessness,i
rr
it
abi
l
ity
,st
if
fnessoft
heneck,cont
ract
ionoft
he
j
aw muscl
es,pai
nfulbr
eat
hinget
c. Somet
imest
hedi
seasemaybeduet
olocal
suppur
ati
on(
pusf
ormat
ion)suchasot
it
ismedi
a,i
nfl
ammat
ionofmi
ddl
eeart
hisi
s
cal
l
edOt
ogeni
ctet
anus.
ModeofI
nfect
ion:
1.ExogenusI
nfect
ion:Cl
.Tet
aniappear
stobeder
ivedpr
imar
il
yfr
om t
hef
aeces
ofani
mal
sandi
ndi
rect
lyv
iasoi
l
.Theyar
eespeci
all
ypr
eval
enti
nmanur
edsoi
l
.The
spor
esofCl
.Tet
aniar
ecommoni
ndustandsoi
lwhi
char
econt
ami
nat
edbyhor
seor
cowdungs.Thegr
owt
hoft
heor
gani
smsi
spr
omot
edbyt
heanaer
obi
ccondi
ti
onand
al
sobyt
hepr
esenceofdeadt
issueandef
fusedbl
ood. Occasi
onal
l
ysomei
njur
ies
causedbycont
ami
nat
edspl
i
nter
s,r
ust
lynai
l
sandt
hor
npr
ickmaycauset
etanus.
2.EndogenousI
nfect
ion:Whenaper
soni
shar
bour
ingCl
.Tet
alii
nint
est
ine,
t
etanusmayr
esul
tfol
l
owi
ngsept
icabor
ti
onandpuer
per
alsepsi
s.Thespor
esr
emai
n
dor
mantt
il
lfav
our
abl
eenv
ironmenti
sav
ail
abl
e.Af
terent
ryi
ntot
hebodyt
hespor
es
ger
minat
eunderf
avour
abl
econdi
ti
onssuchasl
ow oxy
gent
ensi
oni
ndeepwound,
pr
esenceofnecr
oti
cti
ssueandassoci
atedpy
ogeni
cinf
ect
ionoft
hewound.
Cl
ini
calf
eat
ures
Spast
icpar
aly
sisandmuscl
espasmsmaydev
elopatt
hesi
teoft
hel
esi
onandi
f
unt
reat
edbecomegener
ali
zed.Per
ior
almuscl
espasm (
ri
sussar
doni
cus)andspi
nal
spasm (
opi
sthot
onus)maydev
elop.Spasmsar
epai
nful
,maybest
imul
atedbyl
i
ghtor
suddennoi
seandmaycompr
omi
ser
espi
rat
ionsot
hatsecondar
ybact
eri
alpneumoni
a
maydev
elop.Di
agnosi
sisbased onhi
stor
yand cl
i
nicalf
eat
ures;i
sol
ati
onoft
he
or
gani
sm i
snotdi
agnost
ic.

33
Labor
ator
yDi
agnosi
s:
Speci
mens:Woundswab,
exudat
esort
issuef
rom t
hewound.
1.Di
rectSmearandGr
am’
sSt
aini
ng:I
tmayshowsGr
amposi
ti
vebaci
l
liwi
th
dr
um st
ickappear
ance.
2.Cul
tur
e:Cul
tur
eisdonei
nbl
oodagarandami
nogl
ycosi
debl
oodagarmedi
a
underanaer
obi
ccondi
ti nRober
onsori sson’
scookedmeatmedi
um.
Pr
ophy
laxi
s:
I
mmuni
zat
ionwi
tht
etanust
oxoi
dist
hebestweaponagai
nstt
het
etanus.
1.Act
iveI
mmuni
sat
ion:
I
mmuni
singAgent
:Tet
anust
oxoi
d,pr
epar
edbydet
oxi
fyi
ngt
het
oxi
n(t
oxoi
d)
wi
thf
ormal
i
n(For
malToxoi
d)orbyadsor
bingt
oxoi
dint
o al
umi
nium hy
drox
ideor
phosphat
e(APT)
.
DosaShedul
e:I
nit
ial
l
y2dosesoft
oxoi
d(APT)of 0.
5mleachar
einj
ect
ed
i
ntr
amuscul
arl
yatan i
nter
valof6 weeks. The 3rd i
nject
ion oft
oxoi
d(0.
5ml
)is
admi
nist
eral
aft
er6–12mont
hs(
Tri
aldose)
.
Usual
l
yimmuni
zat
ioni
scar
ri
edouti
nal
lchi
l
drendur
ingf
ir
sty
earofl
i
febyDPT
v
acci
necont
aini
ngdi
pht
her
iat
oxoi
d,per
tusi
svacci
neandt
etanust
oxoi
d.I
tconf
ers
i
mmuni
tyf
or7–10day
s.Aboost
eri
nject
ionsoft
oxoi
disgi
venaf
ter5y
ear
sonent
ry
i
ntoschool
andt
her
eaf
terbooset
erdosei
sgi
venev
ery7–10y
ear
s.
2.Passi
veI
mmuni
sat
ion:
Ant
it
etanusser
um (
tet
anusant
it
oxi
n)i
sobt
ained byi
mmui
sing hor
seswi
th
t
oxoi
d.I
tisgi
venbyi
ntr
amus-
cul
arl
yaf
teri
njur
yforsy
stemi
cpr
otect
ionagai
nstt
oxi
n.
I
nject
ionofATSmayber
epeat
edatweekl
yint
erv
als.Thedosei
ssamef
orchi
l
drenand
adul
ts.ATScauseshy
per
sensi
ti
vi
tyr
eact
ions.
I
nsomepar
tsoft
hewor
ld,new bor
nebabi
escommonl
ydi
eoft
etanusasa
r
esul
tofcut
ti
ngt
heumbi
l
icalcor
dwi
thunst
eri
l
izedi
nst
rument
scont
ami
nat
edwi
thCl
.
Tet
ani
.So,
topr
eventt
hiski
ndofmor
tal
i
typr
egnantar
eimmuni
zedwi
thDPT.
Tr
eat
ment
:Iti
sdonebyadmi
nist
rat
ingant
it
oxi
ntoneut
ral
i
zet
het
oxi
nwhi
chi
snoty
et
at
tachedt
othemot
oner
ves.Butt
hisant
it
oxi
ncannotneut
ral
i
zet
heexot
oxi
nwheni
tis
al
readyboundt
oner
vet
issue,
soi
tisi
nef
fect
ivei
ntr
eat
mingt
hedi
seasei
nmi
l
dcases.
I
naddi
ti
ont
oant
it
oxi
n,t
hewoul
dmustbecl
eansedt
hor
oughl
y;al
lnecr
oti
c

34
t
issuei
sremov
edandant
ibi
oti
cpeni
cil
l
ini
sgi
vent
othepat
ientt
oki
l
lthev
eget
ati
ve
cel
l
s.

6.Cl
ost
ri
dium Per
fri
ngens(
GASGANGRENE)
I
NTRODUCTI
ON:
I
tisar
api
dlyspr
eadi
ngoedemat
ousmy
onecr
osi
s,occur
ri
ngchar
act
eri
sti
cal
l
yin
associ
ati
on wi
th sev
ere wounds ofext
ensi
ve muscl
e masses,whi
ch hav
e been
cont
ami
nat
edwi
thpat cCl
hogeni ost
ri
dia,
par
ti
cul
arl
ywi
thCl
ost
ri
dium Per
fri
ngens.
PREDI
SPOSI
NGFACTORS:
1)Ext
ensi
vewoundswi
thheav
ycont
ami
nat
ion
2)RoadAcci
dent
s
3)I
njur
yinv
olv
ingcr
ushi
ngofl
argemuscl
emasses
4)Sur
gical
Oper
ati
ons
ENTRYOFCLOSTRI
DIAI
NTOWOUNDORTI
SSUE:
1)Al
ongwi
thi
mpl
ant
edf
orei
gnpar
ti
clessuchassoi
l
,roaddust
,bi
tsofcl
othi
ng
2)Endogenous Cl
ost
ri
dia on per
ineum and t
highs mayent
ert
hrough sur
gical
pr
ocedur
esort
hroughi
nject
ions.
TYPESOFANAEROBI
CWOUNDI
NFECTI
ONS:
1.Si
mpl
eWoundCont
ami
nat
ion:Ther
eisnoi
nvasi
onofunder
lyi
ngt
issue,j
ust
cont
ami
nat
ionofwoundwi
thCl
ost
ri
diai
sseen,
whi
chdel
ayswoundheal
i
ng.
2.Anaer
obi
cCel
lul
it
is:Cl
ost
ri
diai
nvadet
hef
aci
alpl
aneswi
thmi
nimalt
oxi
n
pr
oduct
ionandnoi
nvasi
onofmuscl
eti
ssue.Ther
eisser
opur
ulentdi
schar
gef
rom t
he
woundwi
thanof
fensi
veodour
.
3.Anaer
obi
c My
osi
ti
s or Gas Gangr
ene:Mostser
ious,associ
ated wi
th
Cl
ost
ri
diali
nvasi
onofheal
thmuscl
eti
ssueandabundantf
ormat
ionofexot
oxi
ns.I
t
occur
sonl
yifcondi
ti
onsar
efav
orabl
eforgasgangr
enet
ooccur
.
CONDI
TIONSFAVOURABLEFORGASGANGRENE:
Lowoxy
gent
ensi
oni
sachi
evedt
hrought
hef
oll
owi
ngev
ent
s:-
Ti
ssuedamageandcont
ami
nat
ionwi
thCl
ost
ri
dial
spor
esandpy
ogeni
cor
gani
sms

Pr
esenceoff
orei
gnbodi
esi
ncl
udi
ngsoi
lwi
thdamagi
ngsal
ts

35
 I
nfl
ammi
styr
eact
ion

Ext
rav
asat
ionoff
lui
d;ocdema

I
mpai
redt
issueper
fusi
on;
stasi
s

Anoxi
aofmuscl
esduet
opooroxy
gensuppl
ywi
thr
educt
ioni
nEhandpHoft
issue

I
mpai
redphagocy
tosi
sandbact
eri
cidal
mechani
smsf
avourmul
ti
pli
cat
ionoff
acul
tat
ive
bact
eri
a

Fur
therr
educt
ioni
nEhandpHduet
oanaer
obi
creduct
ionofpy
ruv
atet
olact
ateand
r
educt
ionhaemogl
obi
nandmy
ogl
obi
n,whi
chceasest
oactasoxy
gencar
ri
ers.

Asar tCl
esul ost
ri
diamul
ti
plyandel
abor
atet
oxi
nswhi
chcausef
urt
herdamage
t
issues.
1)Leci
thi
nasedamagescel
lmembr
anesandi
ncr
easescapi
l
lar
yper
meabi
l
ity
l
eadi
ngt
oext
raandi
ncr
easedt
ensi
oni
ntheaf
fect
edmuscl
es,
causi
ngf
urt
her
anoxi
cdamages.
2)Col
lagenasedest
roy
scol
l
agenbar
ri
ers.
3)Hy
alur
oni
dasesbr
eakdowni
nter
cel
l
ularsubst
ancesf
urt
her
ingi
nvasi
vespr
ead
ofCl
ost
ri
dia
4)AbundantGasr
educest
hebl
oodsuppl
yst
il
lfur
therbypr
essur
eef
fect
s
I
tthusbecomespossi
blef
ort
hei
nfect
iont
ospr
eadf
rom t
heor
igi
nal
sit
e,*
***
l
esi
onapr
ogr
essi
veone.
I
NCUBATI
ONPERI
OD:
10t
o48hr
s - C.Per
fri
gnes
2t
o3day
s - C.Sept
icum
5t
o6day
s - C.Nov
yi
CLI
NICALMANI
FESTATI
ONS:

36
  I
ncr
easedpai
n,t
ender
ness,
oedemaoft
heaf
fect
edpar
ts
 Thi
nwat
erydi
schar
gef
rom t
hewound,
whi
chl
att
erbecomesser
osangui
nous
 Ti
ssuebecomescr
epi
tantduet
oaccumul
ati
onofgas
 Pr
ofoundt
oxemi
aandpr
ost
rat
iondev
elop
 Deat
hisduet
oci
rcul
ator
yfai
l
ure
LABORATORYDI
AGNOSI
S:
Di
agnosi
scanbemadeoncl
i
nical
groundsandl
abdi
agnosi
sisr
equi
redonl
yto
t
hecl
i
nical
diagnosi
sandt
oenumer
atet
hei
nfect
ingor
gani
sms.
Labdi
agnosi
sal
sohel
pst
odi
ff
erent
iat
ebet
weengasgangr
eneandat
St
rept
ococcal
myosi
ti
s,whi
chmaybei
ndi
sti
ngui
shabl
ecl
i
nical
l
y.
SPECI
MENS:
1.Exudat
efr
om t
hewound,
par
ti
cul
arl
yfr
om deeperpar
tsorwher
einf
ect
ioni
s
mostpr
onounced
2.Necr
oti
cti
ssuef
rom t
hewound.

MI
CROSCOPI
CEXAMI
NATI
ONWI
THGRAM STAI
N:
Thi
ckst
ubbygr
am posi
ti
ver
odswi
thoutspor
espr
edomi
nat
e. I sC.
tsuggest
Per
fri
ngensorC.Sor
del
l
ii
.
Ci
tr
onbodi
es,boatorl
eafshapedpl
eomor
phi
cbaci
l
liwi
thi
rr
egul
arst
aini
ng
i
ndi eC.Sept
cat icum.
MEDI
AUSEDFORCULTURE:
Reber
tson’
scookedmeal
brot
h(RCMB)–i
ncubat
eaer
obi
cal
l
y.
Bl
ood agarwi
th Neomy
cin and Egg y
olk agarwi
th Neomy
cini
ncubat
ed
anacr
obi
cal
l
y.
WI
LLI
SANDHOBBSMEDI
UM –CONSTI
TUENTS:
Agar - Eggy
olksuspensi
on
Lact
ose - Mi
l
k
Neut
ral
red - Neomy
cinsul
phat
e
Neomy
cini
nhi
bisBaci
t l
lus,
Staphy
lococcusandcol
i
for
m baci
l
li
.
EXAMI
NATI
ONOFCULTURES:
I
nRCM:Gr
owt
hisseen1cm bel
ow t
het
opoft um.C.Per
hemedi fri
ngensi
s

37
sacchar
oly
ticandhencei
ttur
nsmeatpar
ti
clespi
nk.
OnBA:Nonswar
ming,t
argethemol
ysi
s– r
esul
ti
ngf
rom anar
row zoneof
compl
etehemol
ysi
sduet
othet
atoxi
nandmuchwi
derzoncofi
ncompl
etehemol
ysi
s
duet
oal
phat
oxi
nonl
ongeri
ncubat
ioni oducedbyC.Per
spr fri
ngens.
On EYA:Pi
nkcol
oni
es wi
th opal
escences due t
olact
ose f
erment
ati
on and
l
eci
thi
nasepr
oduct
ion.

PROPHYLAXI
S:
Passi
veI
mmuni
sat
ion:Wi
th ant
i-
gasgangr
eneser
um (
equi
nepol
yval
entant
i-
toxi
n
( U)ofC.Per
1000I fri
gens,C.Nov
yi,C.Sept
icum each)gi
veni
ntr
amuscul
arl
yori
n
emer
gencyi
ntr
avenousl
yisacommonpr
act
icei
npr
ophy
laxi
s.
Act
iveI
mmuni
sat
ion:Wi
tht
oxoi
dsi
nducesgoodant
it
oxi
cresponsei
nexper
iment
sbut
hasnocl
i
nical
appl
i
cat
ioni
npr
event
ionsofgasgangr
ene.

TREATMENT:
Sur
ger
yismosti
mpor
tant
,al
ldamagedt
issuesshoul
dber
emov
edpr
ompt
lyand
woundsi
rr
igat
edt
oremov
ebl
oodcl
ots,necr
oti
cti
ssueandf
orei
gnmat
eri
als. I
n
est
abl
i
shedgasgangr
ene,
exci
sionofal
laf
fect
edpar
tsmaybel
i
fesav
ing.
Ant
ibi
oti
csdr
ugofchoi
cei
sMet
roni
daz
olegi
veni
ntr
avenousl
ybef
oresur
ger
y
andr
epeat
ed8hour
lyf
or24hr
s.I
nmi
xedi
nfect
ion,combi
nat
ionofMet
roni
dazol
e,
Gent
amy
cinandAmoxy
cil
l
ini
sadv
isabl
e.

7.CLOSTRI
DIUM BOTULI
NUM
Mor
phol :Cl
ogy .Bot
uli
num i
sal
arge,Gr
am posi
ti
ve,r
odshaped,noncapsul
ated
baci
l
lusmeasur
ing4–8m x0.
8–1.
2m.I
tismot
il
eduet
oper
it
ri
chousf
lagel
l
aand
showssubt
ermi
nal
,ov
alandbul
gingspor
es.Thev
eget
ati
vecel
l
smayoccursi
ngl
yori
n
chai
ns.
Cul
tur
alChar
act
ers:
Cl
ost
ri
dium bot
uli
num gr
owswel
lonnut
ri
entagarandbl
oodagarmedi
ain
anaer
obi
ccondi
ti
onsandi
nRober
tson’
scookedmeatmedi
um i
n24–48hr
s.atan
opt
imum t
emper
at eof35oC,
ur PH 6.
8.I
tisast
ri
ctanaer
obe.Sur
facecol
oni
esar
elar
ge,

38
i
rr
egul
ar,smit
ranspar
entwi
thf
imbr
iat
e bor
der
. I
n bl
ood agarmedi
um,t
her
eis
hemol
ysi
sar
oundt
hecol
oni
es.Gr
owt
honAl
kal
i
ne,
glucosegel
ati aat20–25oC
nmedi
pr
oducest
hespor
es.
Cl
assi
fi
cat
ion:
Basedoni
mmunol
ogi
caldi
ff
erencesi
nthet
oxi
nspr
oduct
ionbyCl
.Bot
uli
num 8
t
ypesofor
gani
smshav
ebeeni
dent
if
ied.Theyar
eA,
B,C1,
C2,
D,E,
FandG.Thet
oxi
ns
pr
oducedbydi
ff
erentt
ypesar
eident
icali
nthei
rphar
macol
ogi
calact
ivi
ty,buyar
e
neut
ral
i
zedbyt
hei
rspeci
fi
chomol
ogousant
iser
um.A,B,EandFar
eresponsi
blef
or
mosthumanbot
uli
sm,
typeCandDaf
fectbi
rdsandcat
tl
es.
Pat
hogenesi
s:
- Bot
uli
sm i
soft
hreet
ypes(
1)f
oodbor
ne(
2)woundand(
3)i
nfantbot
uli
sm.
- Foodbor
nebot
uli
sm i
sduet
oingest
ionofpr
efor
medt
oxi
n.
SOURCES:
Meatandmeatpr
oduct
sinEur
ope.
Fi
shi
nJapan,spi
ced,smoked,v
acuum packedorcannedal
kal
i
nef
oodst
hatar
eeat
en
wi
thoutcooki
ngar
ethemostcommonof
fender
s. I
nsuchf
oods,spor
esofbaci
l
li
ger
minat
eunderanaer
obi
ccondi
ti
onsgr
owandpr
oducet
oxi
n.
Ty
pesr
elat
edt
ohumandi
seasei
susual
l
ycausedbyt
ypesA,
B,E,
rar
elyF,
C&D
ar
eassoci
atedwi
thout
breaksi
ncat
tl
eandf
owl
.Ty
peGassoci
atedwi
thsuddendeat
h
i
nfewpat
ient
s.
I
ncubat
ionper
iods:
12-
36hr
s.
CLI
NICALMANI
FESTATI
ON:
Vomi
ti
ng,t
hir
st,const
ipat
ion,ocul
arpar
esi
s,di
ff
icul
tyi
nswal
l
owi
ng,speaki
ng
andbr
eat
hing,
comaordel
i
rium super
vene.Deat
hisduet
orespi
rat
oryf
ail
ureoccur
ri
ng
1-
7day
saf
teronset
.Fat
ali
tyr
atev
ari
esf
rom 25-
70%.
WOUNDBOTULI
SM:
- I
tisar
arecondi
ti
on
- I
tresul
tsf
rom woundi
nfect
ionwi
thC.Bot
uli
mum
- Toxi
nispr
oducedatt
hesi
teofi
nfect
ionandi
sabsor
bed.
- Sy
mpt
oms ar
e si
mil
ar t
o f
ood bor
ne bot
uli
sm, but gast
roi
ntest
inal
mani
fest
ati
onsar
eabsent
.

39
 - Ty
peAhasbeenr
esponsi
blef
ormostcases.
I
NFANTBOTULI
SM:
I
tisat
oxi
co-
inf
ect
ion.
- Spor
esar
eingest
edi
nfood,
getest
abl
i
shedi
ngutandpr
oducet
oxi
ns.
- Seeni
ninf
ant
sbel
ow6mont
hs.
- Sour
ce–Honey

CLI
NICALMANI
FESTATI
ONS:
- Const
ipat
ion,poorf
eedi
ng,l
ethar
gy,weakness,pool
edor
alsecr
eti
onsexcr
ete
cr
y,l
ossofheadcont
rol
.
- Pat
ient
sexcr
etet
oxi
nandspor
esi
nfacces.
- Tr
eat
mentconsi
stsofsuppur
ati
vecar
eandassi
stedf
eedi
ng.
LABDI
AGNOSI
S:
Speci
mensar
efoodandf
aeces,v
omi
t,gast
ri
cfl
uid,ser
um,soundt
issueor
exudat
e.
METHODS:
(
i) Demonst
rat
ionofbaci
l
lif
rom speci
mens.
(
ii
) Cul
tur
e
(
ii
i) Ani
mal
test
s
(
iv) Demonst
rat
ionofAnt
ibodi
esi
nSer
um
(
v) Det
ect
ionoft
oxi
nfr
om speci
mens.
1)Mor
phol
ogy
:Iti
saGr
am posi
ti
vebaci
l
lus,non-
capsul
ated,mot
il
eandpr
oduci
ng
subt
ermi
nal
oval
bul
gingspor
es.
2)Cul
t e:Cl
ur ost
ri
dium Bot
uli
num I
sol
ati
on Medi
um (
CBI
)cont
aini
ng egg y
olk
suspensi
on,y
eastext
ract
,Gl
ucose,pept
one,cy
closer
ine,sul
phamet
hoxazol
e,
i
ncubat
ethepl
atesanacr
obi
cal
l
yaf
teri
nocul
ati
on.Col
oni
esar
elar
gei
rr
egul
ar
semit
ranspar
entwi
thf
imbr
iat
edbor
der
.Spor
esar
ebet
terpr
oducedwhengr
own
i
nal
kal
i
negl
ucosegel
ati aat20o-25oC.
nmedi
3)Ani
malPat
hogeni
cit
yTest
:Int
raper
it
oneali
nocul
ati
onsofcul
tur
efl
uidi
ntomi
ce
gi
ver
iset
orespi
rat
orydi
ff
icul
tyi
nani
mal
swi
thi
naf
ew hour
s. Waspwai
st
appear
ance due t
o par
aly
sis ofabdomi
nalmuscl
es;gener
ali
zed par
aly
sis

40
 dev
elopsandani
maldi
esi
n18-
24hr
s.Congest
ion,t
hrombosi
sandhemor
rhage
ar
eseeni
nint
ernal
organsataut
opsy
.
4)Det
ect
ionofToxi
ns:
- Li
qui
dext
ract
sofsol
i
dsampl
esar
epr
epar
edbyhomogeni
zat
ionwi
thequal
v
olumeofsal
i
neandcent
ri
fugat
ion.
- Tr
eatt
heext
ractwi
tht
rypsi
nwhi
chact
ivat
est
het
oxi
ns.
- Chal
l
engemi
cei
ntr
aper
it
oneal
l
y.
- Pr
otectone ani
mal(
cont
rol
)wi
thi
ntr
aper
it
oneali
nocul
ati
on ofpol
yval
ent
bot
uli
num ant
it
oxi
n.

Resul
t:
Unpr
otect
edani
mal
recei
vi
ngsampl
edue,
whi
l
epr
otect
edani
mal
sur
viv
econf
ir
m
bot
uli
num t
oxi
n.
Ty
pingi
sdonebypr
otect
ingt
heani
mal
wit
hty
pespeci
fi
cant
iser
a.

Pr
event
ionandCont
rol
:
- Pr
opercanni
ngandpr
eser
vat
ions.
- Pr
ophy
lact
icdoseofant
itoxi
nshoul
dbegi
venI
Mtoal
lwhoconsumedar
ti
cleof
f
ood.
- Al
umi
nium adsor
bedt
oxoi
dmaybegi
venatani
nter
val
of10weeks,
2doseswi
th
aboost
ery
earaf
ter
.Iti
sgi
venf
ort
hoseexposedt
ori
skofbot
uli
sm.
- Pol
yval
entant
iser
atot
ypeA,B,Emaybeadmi
nist
eredassoonascl
i
nical
di
agnosi
sisman.
- Suppor
ti
ver
espi
rat
oryt
her
apyi
sal
soi
mpor
tant
.
1.Adequat
ingcooki
ngf
oods.2.Educat
ingt
hepeopl
eonsaf
ehome
pr
epar
ati
onandpr
event
ionoff
oods(
canni
ng)3.Notf
eedi
nghoney
t
othei
nfant
sast
hati
scont
ami
nat
ed.

Tr
eat
ment
:
Admi
nist
eri
ng t
he ant
it
oxi
nint
ra-
venousl
ytr
eat
s bot
uli
sm case. I
t onl
y
neut
ral
i
zest
heci
rcu-
lat
ingt
oxi
n,butt
hener
vesal
readyaf
fect
srecov
erv
erysl
owl
y

41
r
equi
ri
ngweeksormont
hs.

10.CORYNEBACTERI
UM DI
PHTHERI
AE
Mor
phol
ogy
:
C.Di
pht
her
iaei
sacl
ubshapedi
nvol
uti
onf
orm orsl
enderr
edshaped(
nor
mal
f
orm)
,nonmot
il
e,noncapsul
ated,nonspor
ingandGr
am posi
ti
vebact
eri
a.Theyar
e
pl
eomor
phi
candmeasur
ingappr
oxi
mat
ely3–6m x0.
6–0.
8.Thebaci
l
limayexi
st
i
npai
rsorgr
oups.Theycommonl
yshow Chi
nesel
ett
erpat
ter
n(V,L,X)orcuni
for
m
ar
rangement
.Thecel
l
sshowsept
aand‘
Pol
ymet
aphosphat
egr
anul
es’
int
hecy
topl
asm
whenst
ainedwi
thLoef
fl
er’
smet
hyl
enebl
ue,
thegr
anul
est
akeupabl
uishpur
plecol
our
andhencet
heyar
ecal
l
edmet
achr
omat
icgr
anul
es
Cul
tur
alChar
act
eri
sti
cs:
Gr
owt
hisscant
yonor
dinar
ymedi
aEnr
ichmentwi
thbl
ood,ser
um,oreggi
s
necessar
yforgoodgr
owt
h.Theopt
imum t
emper
atur
eforgr
owt
his37oc(
range15oc-
40oc)andopt
imum pH i
s7.
2.I
tisanaer
obeandf
acul
tat
iveanaer
obe.OnLoef
fl
er’
s
ser
um agarmedi
um,t
hebact
eri
aourgr
owsassmal
l
,gr
anul
ar,moi
st,cr
eamycol
oni
es
whi
chgi
vesat
ypi
calmor
phol
ogy
. Onpot
assi
um t
ell
uri
tebl
oodagarmedi
um,t
hey
sel
ect
ivel
ygr
owandf
orm bl
ackcol
ourcol
oni
es.

Bi
o-Chemi
calReact
ions:
Di
pht
her
ia baci
l
lif
ermentgl
ucose,gal
act
ose,mal
tose and dext
ri
n,butnot
l
act
ose,
manni
tolorsucr
ose.Onf
erment
ati
ont
heypr
oduceaci
dbutnogas.Thesear
e
cat
alaseposi
ti
ve.Theyr
educeni
tr
atesanddonothy
drol
ysegel
ati
n.
Ant
igeni
cSt
ruct
ure:
Di
pht
her
iabaci
l
liar
eant
igeni
cal
l
yhet
erogenous.Byaggl
uti
nat
iongr
avi
sst
rai
ns
ar
ecl
assi
fi
edi
nto13t
ypes,
int
ermedi
usi
nto4t
ypesandmi
ti
sint
o40t
ypes.
Pat
hogeni
cit
y:
Thei
ncubat
ionper
iodi
ndi
pht
her
iai
scommonl
y3–4day
s,butmayonoccasi
on
beasshor
tasoneday
.C.di
pht
her
iaent
erst
hebodyt
hroughr
espi
rat
oryt
ractby
i
nhal
ati
on.Si
teofi
nfect
ionmaybef
auci
al,
lar
yngeal
,nasal
,ot
it
ic,
conj
unct
ival
,geni
tal
&
cut
aneous.

42
 Fauci
aldi
pht
her
iai
sthecommonestt
ypeandmayv
aryf
rom mi
l
dcat
arr
hal
i
nfl
ammat
iont
over
ywi
despr
eadi
nvol
vement
.Accor
dingt
othesev
eri
tyofdi
seasei
t
canbecl
assi
fi
edas.
1)Mal
ignantorHy
per
toxi
c:Sev
eret
oxemi
awi
thcer
vical
adeni
ti
s(bul
l
ock)
,deat
hmay
beduet
orespi
rat
oryf
ail
ure.
2)Sept
icl
eadst
oul
cer
ati
on,
cel
l
uli
ti
sandgangr
enear
oundpseudomembr
ane.
3)Haemor
rhagi
c:Bl
eedi
ngf
rom t
heedgesofmembr
aneofnose,
eyeset
cseen.

Di
pht
her
iai
scausedbyCor
ynebact
eri
um di
pht
her
iaet
hatcont
ainabact
eri
ophage
encodi
ngdi
pht
her
iat
oxi
n.Thet
oxi
nki
l
lscel
l
sbyi
nter
rupt
ingpr
otei
nsy
nthesi
s,act
ing
ont
hemy
ocar
dium t
ocausemy
ocar
dit
isandont
heper
ipher
alner
voussy
stem t
o
causeneur
opat
hyandpar
aly
sis.Thesev
eri
tyofi
nfect
ioni
sdi
rect
lyr
elat
edt
othe
degr
eeoft
oxi
npr
oduct
ion.Cut
aneousi
nfect
ioni
sof
tenasy
mpt
omat
ic.

Cor
ynebact
eri
um di
pht
her
iaei
str
ansmi
tt
edbyt
her
espi
rat
oryr
out
eorf
oll
owi
ngdi
rect
cont
actwi
thcut
aneousl
esi
ons.

CLI
NICALMANI
FESTATI
ONS:
Mal
aise,
fat
igue,
fev
er,
sor
ethr
oat
,adher
entpseudomembr
anef
ormat
ionar
ound
sof
tpal
ateuv
ula,phar
yngealwal
landnasalmucosa,oedema,heatandt
ender
nessi
n
t
heant
eri
ort
issuesoft
heneck(
bul
lneck)andl
ocall
ymphadenopat
hy.I
nfect
ionoft
he
ski
n,nasophar
ynxorl
ary
nxmayoccur
;thesev
eri
tyofdi
seasei
srel
atedt
otheext
entof
t
hei
nfect
ion.Ar
arecauseofsor
ethr
oat
,itcausesi
nfl
ammat
ionandnecr
osi
sgi
vi
nga
gr
een-bl
ack'
pseudomembr
ane'ont
hepost
eri
orwal
loft
hephar
ynx,whi
chcancause
r
espi
rat
oryobst
ruct
ion.Managementi
sbasedoni
sol
ati
onandt
reat
mentwi
thant
it
oxi
n
ander
ythr
omy
cin.I
ntensi
vecar
esuppor
tmayber
equi
red.

LABORATORYDI
AGNOSI
S:
I
tisdi
agnosedcl
i
nical
l
yandconf
ir
mat
ioni
snecessar
yfort
hei
nit
iat
ionofcont
rol
measur
esandf
orepi
demi
ologi
cal
pur
pose.
METHODS:
1)Pr
obabl
edi
agnosi
s–basedont
hedemonst
rat
ionofbaci
l
lif
rom smear
s.

43
 2)I
sol
ati
onofdi
pht
her
iabaci
l
lus.
3)Demonst
rat
ionofi
tst
oxi
cit
y.
Speci
men:Thr
oatswabf
orf
auci
aldi
pht
her
ia.
DI
RECTMI
CROSCOPY:
1)Gr
anSt
ainofSmearshows
- Gr
am posi
ti
vesl
enderr
ods
- Nonspor
ing,
noncapsul
ate,
nonmot
il
e
- Baci
l
liar
e ar
ranged atangl
est
o one anot
heri
nthe f
orm ofV orL.Thi
s
ar
rangementi
scal
l
edChi
nesel
ett
erar
rangementorCunei
for
m ar
rangement
.
2)Speci
alSt
ains:Al
ber
tsSt
ainshowsgr
eenbaci
l
liwi
thbl
uishbl
ackgr
anul
es.
Ponder
sSt
ain Al
ber
t’
sSt
ain
- Ponder
sSt
ainshowsbl
uebaci
l
liwi
thpur
ple,
met
achr
omat
icgr
anul
es
- St
impl
eSt
ain:Locef
fl
ersMet
hyl
enebl
ueshowsbl
uebaci
l
liwi
thbl
uishpur
ple
met
achr
omat
icgr
anul
es.
Pr
obabl
eDi
agnosi
s:
Pr
esenceofgr
am posi
ti
vebaci
l
liwi
that
ypi
calCunei
for
m ar
rangementwi
th
met
achr
omat
icgr
anul
esf
rom t
hedi
rectspeci
mengi
vest
hepr
obabl
edi
agnosi
sof
di
pht
her
iaco-
rel
atedt
ocl
i
nical
sympt
oms.
CULTURE:
Speci
menhast
obei
nocul
atedont
o
1)Loef
fl
ersSer
um Sl
ope:
12% ox,sheeporhor
seser
um i
nnut
ri
entbr
othst
eri
l
izedbyi
nspi
ssat
ions. I
t
enhancest
her
api
dgr
owt
handf
ormat
ionofmet
achr
omat
icgr
anul
es.Gr
owt
hoccur
s
wi
thi
n6hr
s.
2)Sel
ect
iveMedi
a:
Bl
oodTel
l
uri
teAgar(
BTA)
Ser
um Tel
l
uri
teAgar(
STA)
Chocol
ateTel
l
uri
teAgar(
CTA)
Pot
assi
um t
ell
uri
te(
0.03-
0.04%)i
nhi
bit
sthegr
owt
hofmostor
alcommensal
es
andr
etar
dst
hegr hofCandi
owt daAl
bicunsandSt
aph,aur
eus,
buthasl
i
ttl
eef
fecton
di
pht
her
iabaci
l
liwhi
chconv
ert
stel
l
uri
teont
ell
uri
um whi
chpr
eci
pit
atest
ogi
vebl
ack

44
col
oni
es.
CULTUREEXAMI
NATI
ON:
1)Loef
fl
ersSer
um Sl
ope:Cr
eami
shy
ell
ow col
oni
esar
epr
oducedwi
thi
n6hr
s.
Makesmear
sandl
ookf
ormet
achr
omat
icgr
anul
esbydoi
ngspeci
alst
ains,i
f
di
pht
her
ia,baci
l
liwi
thmet
achr
omat
icgr
anul
esar
efound,war
nthecl
i
nici
anof
t
hepossi
bil
i
tyt
hatt
hepat
ienthasdi
pht
her
ia.Subcul
tur
efr
om posi
ti
veser
um
sl
opest
obl
oodt
ell
uri
teagari
ncaset
hepr
imar
ycul
tur
eont
hismedi
um f
ail
sto
gr
ow.
2)Bl
oodTel
lur
it
eAgar(
BTA)Gr
ay-
blackcol
oni
esar
epr
oducedduet
oreduct
ionof
t
ell
uri
tei
sthemedi
um.

Pr
event
ionandcont
rol
Di
pht
her
iai
spr
event
edbychi
l
dhoodv
acci
nat
ionwi
that
oxoi
d.I
mmuni
tyi
slong-
last
ing
butboost
ersf
oradul
tsatext
rar
iskmayber
equi
red(
e.g.l
abor
ator
yst
aff
).Cont
act
sof
casesmustbei
dent
if
iedandgi
venant
ibi
oti
cpr
ophy
laxi
s,v
acci
nat
ionand/
orspeci
fi
c
ant
it
oxi
n.
Tr
eat
ment
:
Speci
fi
ctr
eat
mentofdi
pht
her
iaconsi
stsofant
it
oxi
candant
ibi
oti
cther
apy
.
Cdi
pht
her
iai
ssensi
ti
vet
openi
cil
l
inandcanbecl
ear
edf
rom t
het
hroatwi
thi
na
f
ewday
sbypeni
cil
l
int
reat
ment
.

Gr
am-
negat
ivecocci

2.NEI
SSERI
AGONORRHOEAE
Mor
phol
ogy
:
N.gonor
rhoeaei
sadi
plococcuswi
tht
headj
acentsi
desconcav
e.I
tshows
t
ypi
calr
eni
for
m orpearshape.I
tisi
ntr
acel
l
ulari
npol
ymor
phs(
PMNLs)i
nur
ethr
alpus.
Theyar
enon-
mot
il
e,noncapsul
ated,nonspor
ing,Gr
am negat
ivedi
plococci
c. They
possesspi
l
iont
hei
rsur
facewhi
chhel
pst
hedi
plococci
cinadhesi
ont
o mucosal
sur
facesandpr
omot
evi
rul
encebyi
nhi
bit
ingphagocy
tosi
s.
Pi
l
ial
sohel
pinaggl
uti
nat
ionofhumanRBC.

45
Cul
tur
alChar
act
ers:
Gonococciar
emor
edi
ff
icul
ttogr
owt
hanmeni
ngococci
.Theyar
eaer
obi
cand
f
acul
tat
iveanaer
obi
c.Theyr
equi
re35oC–36oCt
emper
atur
eand7.
2–7.
6pHf
ort
hei
r
bestgr
owt
h.5–10%CO2i
sessent
ial
fort
hei
rgr
owt
h.
Theygr
owwel
lonchocol
ateagarmedi
um andMuel
l
erhi
ntonagarmedi
um.
Sel
ect
ivemedi
um usedf
ori
tsgr
owt
hisThay
erMar
ti
nmedi
um. I
tcont
ains
v
ancomy
cin, col
i
sti
n and ny
stat
in and i
nhi
bit
s most cont
ami
nant
s i
ncl
udi
ng
nonpat
hogeni
cnei
sser
iae.
Col
oni
esar
esmal
l
,round,t
ransl
ucent
,conv
exsl
i
ght
lyumbonat
e,wi
thf
inel
y
gr
anul
arsur
faceandl
obat
emar
gin.Col
oni
esar
esof
tandeasi
l
yemul
sif
iabl
e.
Bi
ochemi
calChar
act
ers:
Theyf
ermentgl
ucosepr
oduci
ngaci
dbutnogas.Theydonotf
ermentmal
tose.
So,
Gonococci
resembl
emeni
ngococci
excepti
nthef
erment
ati
onofmal
tose.
Theyar
ecat
alaseandoxi
daseposi
ti
ve.When1% sol
uti
onofoxi
daser
eagent
(
tet
ramet
hylpar
apheny
lenedi
ami
nehy
drochl
ori
de)i
spour
edont
hecul
tur
emedi
a,
Nei
sser
iacol
oni
est
urndeeppur
ple.Thi
sreact
ionhel
pst
oident
if
yNei
sser
ia.
I
ndol
eandH2Spr
oduct
ioni
snegat
ive.
Ni
tr
atesar
enotr
educed.(
Nit
rat
ereduct
ion-
ve)
Ant
igeni
c Pr
oper
ti
es:Gonococciar
e ant
igeni
cal
l
yhet
erogenous.3 ant
igeni
c
st
ruct
uresar
efoundi
ngonococci
.
(
i) Pi
l
i
(
ii
) Out
ermembr
anepr
otei
ns–Pr
otei
nI,
IIandI
II
.
(
ii
i) Out
ermembr
anel
i
popol
ysacchar
ides–Endot
oxi
n.
Pi
l
iar
ehai
rli
kest
ruct
ures,sev
eralmi
cromet
ersl
ong,composedofpept
ide
subuni
ts(
pil
i
ns)por
ins.Theyhav
econst
antandv
ari
abl
eregi
ons.
Theyactasv
irul
encef
act
orsbyhel
pingi
nat
tachmentt
othehostcel
l
sand
i
nhi
bit
ingphagocy
tosi
s.Theyshowant
igeni
cvar
iat
ion.
Out
ermembr
anepr
otei
nsar
eofdi
ff
erentt
ypes.Pr
otei
nI,
IIandI
IIar
eimpor
tant
amongt
hem.
Pr
otei
nIandI
IIactasl
i
gandsat
tachi
ngt
heGonococcit
othehostcel
l
.They
f
ormt
ransmembr
anechannel
s(por
ins)whi
chpl
ayar
olei
ntheexchangeofmol
ecul
es

46
acr
osst
heout
ermembr
ane.
Pr
otei
nIIi
sresponsi
blef
oropaci
tyofgonococcalcol
oni
es.Soi
tisal
socal
l
ed
“
opaci
tyassoci
atedpr
otei
n”.Thest
rai
nswhi
chhav
ethi
spr
otei
n,f
orm opaquecol
oni
es
andv
icev
ersa.I
thel
psi
nat
tachmentandcl
umpi
ngofcocci
inur
ethr
alexudat
es.
Thel
i
popol
ysacchar
ides(
endot
oxi
n)ar
eresponsi
blef
ort
oxi
cit
yingonococcal
i
nfect
ions.
I
gA1pr
oteasesar
epr
oducedbyNei
sser
iawhi
chspl
i
tandi
nact
ivat
esI
gA.
Pat
hogenesi
s:
Gonor
rheai
sav
ener
eal
diseaseacqui
redbysexual
cont
act
.
Fi
rstst
epi
ninf
ect
ioni
sadhesi
onofgonococcit
otheur
ethr
aorot
hermucosal
sur
faces.
Pi
l
ihel
psi
nadhesi
on.Adhesi
oni
srapi
dandf
ir
m;sot
her
eisnopr
otect
ionaf
ter
exposur
e. Gonococcipenet
rat
ethr
ough t
he i
nter
cel
l
ularspace and r
each t
he
subepi
thel
i
alconnect
ivet
issuewi
thi
n3day
s.Thei
ncubat
ionper
iodi
s2–8day
s.
I
nmen,t
hedi
seasest
art
sasanacut
eur
ethr
it
iswi
thamucopur
ulentdi
schar
ge
hav
ing Gonococci
. I
nfect
ion ext
ends t
o pr
ost
rat
e gl
ands,semi
nalv
esi
cles and
epi
didy
mis.
Chr
oni
cur
ethr
it
isl
eadst
ost
ri
ctur
efor
mat
ion.
I
fitspr
eadst
opr
eur
ethr
alt
issue,
itcausesabscessesandwat
ercanper
ineum.
I
nwomen,
inf
ect
ioni
nvol
vesur
ethr
aandcer
vixut
eriduet dpH andr
oaci esi
stant
st
rat
if
iedsquamousepi
thel
i
um,adul
tsi
ngener
alar
enotaf
fect
ed.I
nPr
epuber
talgi
rl
s,
v
ulv
ovagi
nit
isoccur
s.
I
nwomen,i
nfect
ionext
endst
oBar
thol
i
n’sgl
andsendomet
ri
unandf
all
opi
an
t
ubes.Sal
pingi
ti
smayl
eadt
ost
eri
l
ity
.
Asy
mpt
omat
iccar
ri
ersar
emor
einwoment
hanmen.I
nbot
hsexes,pr
oct
it
is,
conj
unct
ivi
ti
s,ar
thr
it
is,
ulcer
ati
veendocar
dit
is,
rar
elymeni
ngi
ti
smayoccur
.

Labdi
agnosi
s:
Di
agnosi
siseasyi
nacut
est
agest
hani
nchr
oni
ccases.Sampl
esar
ecol
l
ect
ed
f
rom ur
ethr
aldi
schar
gei
nbot
hsex
esandi
nwomen,
cer
vical
swabsar
eal
sousef
ul.
a)Mi
croscopy
:

47
 Asmeari
spr
epar
edf
rom ur
ethr
aldi
schar
ge.I
tisGr
am st
ainedandobser
ved.
I
ntr
acel
l
ularGr
am negat
ivedi
plococcigi
vet
hepr
esumpt
iveev
idencei
nmen. Buti
n
women,
nor
malf
lor
amayhav
esi
mil
armor
phol
ogy
.So,
fluor
escentant
ibodyt
echni
que
i
sused.
b)Fl
uor
escentAnt
ibodyTechni
que:
I
tismor
esensi
ti
veandspeci
fi
cthandi
agnosi
sbymi
croscopy
.
c)Cul
tur
e:
Speci
mens ar
einocul
ated on chocol
ate agarorMul
l
er– Hi
nteragarand
o o
i
ncubat
edat35C–37Cunder5–10%CO2,t
oisol
ateGonococcicul
tur
eshoul
dbe
f
oll
owedbymi
croscopy
.s
Pr
ophy
laxi
s:
Gonor
rhoeacanbecont
rol
l
edbyear
lydet
ect
ionofcases,heal
theducat
ionand
saf
esexual
cont
act
s.Vacci
nat
ionhasnopl
acei
npr
ophy
laxi
s.
Tr
eat
ment
:
Sul
phonami
des,Peni
cil
l
insar
eef
fect
ive.Whent
hest
rai
nsdev
elopr
esi
stance,
cef
uroxi
me,
cef
otaxi
me,
ery
-thr
omy
cin,
tet
racy
cli
ne,
cipr
ofl
oxaci
nar
eusef
ul.

ESCHERI
CHI
ACOLI

Mor
phol
ogy
:
E.col
ii
saGr
am-
negat
ive,
nonspor
ing,
noncapsul
atedbaci
l
lusmeasur
ing1-
3m
x0.
4–0.
7m.Mostst
rai
nsar
emot
il
ebyper
it
ri
chat
efl
agel
l
a,somest
rai
nsmaybenon
mot
il
e.
Gener
alFeat
ures:
E.col
ii
saf
acul
tat
iveor
gani
sm t
hati
spar
toft
henor
malgutf
lor
aofani
mal
sand
humans.E.col
iismot
il
e,f
erment
slact
ose,f
ormsagr
eensheenonEosi
nmy
thl
ene
bl
ueagar
,andgr
owswel
lonsi
mpl
emedi
a.Ref
erencel
abor
ator
iesi
dent
if
yindi
vi
dual
st
rai
nsbyt
hei
rO,H andKant
igenser
oty
pes.E.Coi
lst
rai
nst
hatcausedi
arr
heaar
e
cl
assi
fi
edasent
erot
exi
geni
c(ETEC)
,ent
eropat
hogeni
c(EPEC)
,ent
eroi
nvasi
ve(
EIEC)
,
ent
eroaggr
egat
ive(
EAEC) and ent
erohemor
rhagi
c(EHEC) st
rai
ns.Because t
hey

48
pr
oduceat
oxi
nknownasv
erot
oxi
n,EHECar
eal
socal
l
edv
erot
oxi
geni
c(VTEC)st
rai
ns.
Vi
rul
enceFact
ors:
1.Adhesi
ons:Mor
ethan80% E.Coi
lst
rai
nst
hatcausepy
elonephr
it
shav
eP
f
imbr
iae.EPECor
gani
smsadher
etot
hecol
oni
cmucosav
iat
ypeI
VPi
l
i,whi
char
eal
so
cal
l
edbundl
efor
mingpi
l
i.SomeE.col
ist
rai
nst
hatcausedi
arr
hoeaexpr
esspi
l
iknown
ascol
oni
zat
ionf
act
orant
igens(
CFA)
.
2.Endot
oxi
n:E.Coi
lst
rai
nshav
eanendot
oxi
nli
popol
ysacchar
ideandsy
stemi
c
i
nfeci
ti
onscanl
eadt
osepsi
s.
3.Ent
erot
oxi
ns:Thesear
epr
otei
nexot
oxi
nst
hataf
fectgast
roi
ntest
inalf
unct
ion.
Two E.Col
ient
erot
oxi
nsar
epr
oduced byETEC st
rai
nsand causepr
ofuswat
ery
di
arr
hoea.Theyar
e(1)Heat–l
abi
l
eent
erot
oxi
n(LT)(
2)HeatSt
abl
eent
erot
oxi
n.(
ST)
4.Ver
otoxi
n:EHEC(
VTEC)st
rai
nsofE.col
ipr
oducev
erot
oxi
ns.Thesear
eof
t
wot
ypes.
(
i)Ver
otoxi
n–I–causescel
ldeat
hbyhal
ti
ngpr
otei
nsy
nthesi
s.
(
ii
)Ver
otoxi
n – I
I causes acut
e r
enal f
ail
ure, t
hrombocy
-topeni
a and
mi
croangi
opat
hichemol
yti
canemi
a(Tr
iadchar
act
er)
.
Pat
hogeni
cit
y:
Themaj
ori
tyofE.col
iinf
ect
ionsar
eoppor
tuni
sti
cinf
ect
ions.E.col
iist
hemost
pr
eval
entcause ofnosocomi
ali
nfect
ions. Di
arr
heogeni
c E.Col
ist
rai
ns possess
adhesi
onsandpr
oducet
oxi
nst
hatar
eresponsi
blef
ort
hedev
elopmentofdi
arr
hea.
E.
coi
lcausesdi
ff
erentt
ypesofi
nfect
ions.
(
a)Oppor
tuni
sti
cInf
ect
ions:E.col
ior
gani
smsar
efoundi
nlar
genumber
sinhuman
f
ecesandar
espr
eadv
iaf
ecalcont
aimi
nat
ion.Thef
requencyofnosocomi
alE.
col
iinf
ect
ionsi
ncr
easeswheni
nvasi
vepr
ocedur
es,suchascat
het
eri
zat
ion,ar
e
used.
(
b)Ur
inar
ytr
acti
nfect
ions:Commmuni
tyacqui
red ur
inar
ytr
acti
nfect
ions ar
e
usual
l
yther
esul
tofsel
f-
inf
ect
ionandoccurmostof
teni
nwomen.Ot
herr
isk
f
act
orsf
orur
inar
ytr
acti
nfect
ions i
ncl
ude ur
inar
y cat
het
eri
zat
ion,sexual
i
nter
cour
se,
diabet
esandt
hepr
esenceofki
dneyst
ones.
(
c)Di
arr
healDi
sease:Atl
eastf
ivegr
oupsofE.col
icausedi
arr
hoea.
1.Ent
erot
oxi
geni
cE.
Col
i:ETECst
rai
nscol
oni
zet
hepr
oxi
malsmal
li
ntest
ine,
wher
e

49
 t
heypr
oduceLTorSTandcausewat
erydi
arr
hoea.Thesest
rai
nsar
eacommon
causeofdi
arr
hoeai
nmal
nour
ishedi
nfant
sandar
ethemaj
orcauseoft
rav
eler
’s
di
arr
hea.
2.Ent
eropat
hogeni
c E.col
i:EPEC st
rai
ns adher
e cl
osel
yto ent
erocy
tes i
n
mi
crocol
oni
esv
iat
ypeI
VPi
l
i.Thebact
eri
acauset
hei
ntr
acel
l
ularcal
cium l
evel
s
t
ori
seandt
hemi
crov
il
li
toef
face.I
tiscommoni
ninf
ant
s.
3.Ent
erohemor
rhagi
cE.Col
i:EHECor
gani
smscausecopi
ousbl
oodydi
arr
hoeaby
adher
ingt
othecol
oni
cmucosaandpr
oduci
ngv
erot
oxi
ns.I
tcauseshemol
yti
c–
ur
emi
csy
ndr
ome.
4.Ent
eroi
nvasi
veE.Coi
l:Whent
hesest
rai
nsi
nvadet
hecol
oni
cmucosaandl
ami
na
pr
opr
ia,t
hey cause wat
ery di
arr
hoea t
hatpr
ogr
esses t
o a dy
sent
ery
-l
ike
di
arr
hoea.
5.Ent
eroaggr
egat
iveE.Coi
l:EAECst
rai
nsadher
etot
hecol
oni
cmucosav
iabundl
e
-
for
mingpi
l
iandpr
oduceanent
erot
oxi
nthatcauseswat
erydi
arr
hoea.
6.Ot
herst
rai
nsofE.
Col
i:Non-
toxi
geni
cE.col
ist
rai
nswi
thmannoser
esi
stantpi
l
i
(
CFA/
II
)causepr
olongeddi
arr
-hocai
nmal
nour
ishedpat
ient
svi
aanunknown
mechani
sm.
Labor
ator
yDi
agnosi
s:
a)Oppor
tuni
sti
cInf
ect
ions:E.col
iis a common cause of nosocomi
al
pneumoni
ainpat
ient
swhoar
eov
er50y
ear
sofageandhav
eachr
oni
c
under
lyi
ngdi
sease. Woundsorbowelsur
ger
ymayl
eadt
oE.col
iwound
i
nfect
ionsorpost
oper
ati
vei
nfect
ions. Thesei
nfect
ionsar
edi
agnosedby
cul
tur
ingE.col
ifr
om bl
oodorsampl
esofi
nfect
edt
issue.
b)Ur
inar
yTr
actI
nfect
ions:Pat
ient
smaydev
elopE.col
ii
nfect
ionsoft
heur
inar
y
bl
adder(
Cyst
it
is)oroft
her
enalpar
enchy
maandpel
vi
s(Py
elonephr
it
is)
.
Ur
inar
ytr
acti
nfect
ionsar
edi
agnosedbyt
est
ingandcul
tur
ingami
dst
ream
ur
ine sampl
e. The ur
ine ofpat
ient
swi
th cy
sti
ti
scont
ainser
ythr
ocy
tes,
l
eukocy
tesandbact
eri
a.Theur
ineofpat
ient
swi
thpy
elonephr
it
iscont
ains
er
ythr
ocy
tes,
cast
sandbact
eri
athatar
eant
ibody
-coat
edandcanbedet
ect
ed
v
iaf
luor
escentant
ibodyt
est
s.
c)Di
arr
healDi
sease:I
nmostpat
ient
sE.col
iinf
ect
ioncauseswat
erydi
arr
hoea,

50
 nausea,abdomi
nalcr
amps,andl
ow-
gradef
everet
c. E.col
idi
arr
hoeai
s
di
agnosedbyi
sol
ati
ngt
heor
gani
smsi
ncul
tur
eandt
henusi
ngspeci
ali
zed
t
estt
oident
if
yther
esponsi
blest
rai
n.Exampl
esi
ncl
udeDNA pr
obesand
bi
oassay
sforETEC,t
issuecul
tur
etest
sfori
nvasi
venessofEI
EC,bi
oassay
s
f
orEHEC,
andser
oty
ingf
orEPEC.

Epi
demi
ology
:
Oppor
tuni
sti
cE.col
iinf
ect
ionsar
egener
all
yacqui
redi
nthehospi
talset
ti
ngand
occurmostf
requent
lyi
npat
ient
swhohav
eindwel
l
ingcat
het
ersorunder
-goi
nvasi
ve
pr
ocedur
es. Di
arr
hoea-
produci
ngst
rai
nsofE.col
iar
eacqui
redbyi
ngest
ingf
eces-
cont
ami
nat
edf
oodorwat
er.
Pr
event
ion:
Oppor
tuni
sti
c E.col
iinf
ect
ions can be pr
event
ed by usi
ng st
ri
ctasept
ic
t
echni
quesi
ncl
i
nicalset
ti
ngscanbyav
oidi
ngunnecessar
ycat
het
eri
zat
ion. E.col
i
di
arr
hoeacanbepr
event
edbymai
ntai
ningapot
abl
ewat
ersuppl
y,t
hor
oughl
ycooki
ng
meat
s,past
eur
izi
ngmi
l
kandbr
eastf
eedi
ngi
nfant
s.Hi
gh–r
iski
ndi
vi
dual
smayt
akea
f
luor
oqui
nol
oneant
ibi
oti
caschemopr
ophy
laxi
s.
Tr
eat
ment
:
Ant
ibi
oti
csusedi
nthet
reat
mentofv
ari
ousE.col
iinf
ect
ionsar
ecephal
exi
n,
gent
amy
cin,f
luor
oqui
nol
oneet
c. Pat
ient
swi
thdi
arr
hoeashoul
drecei
vef
lui
dsand
el
ect
ro-
ly
tesasneeded.

SALMONELLATYPHI
Ty
phoi
d (
Sal
monel
l
osi
s) i
s caused by t
he i
ngest
ion of f
ood or wat
er
cont
ami
nat
edwi
thSal
monel
l
aty
phi
.Thedi
seasei
schar
act
eri
zedbyf
ever
,headache,
abdomi
nalpai
n,anor
exi
a,mal
aise,
coat
edt
ongue,
hepat
omegal
y,r
osespot
sont
heski
n
et
c.Ty
phoi
dbaci
l
liwer
efi
rstobser
vedbyEber
th(
1880)
.
Mor
phol
ogy
:Sal
monel
l
aisaGr
am negat
ive,
rodshapedEnt
erobact
eri
um andmeasur
es
about1–3m x0.
5m i
nsi
ze.I
tisact
ivel
ymot
il
ebymeansofper
it
ri
chat
efl
agel
l
a.I
t
i
snon-
capsul
ated,
nonspor
ulat
ingbact
eri
um buti
tmaypossessf
imbr
iae.
Cul
tur
alChar
act
ers:

51
 Sal
monel
l
aty
phigr
owsr
api
dlyonsi
mpl
emedi
a.I
tgr
owsov
erar
angeofpH–
6.
8andt
emper
at e15–41oC(
ur opt
i ng37oC)
mum bei .Col
oni
esar
elar
ge,l
owconv
ex,
ci
rcul
ar,smoot
h and measur
es about2-
3mm i
n di
amet
er. Col
oni
es ar
e mor
e
t
ransl
ucentt
hancol
i
for
m col
oni
es.I
tisaer
obi
candf
acul
tat
ivel
yanaer
obi
c.OnMac
Conkey and Deoxy
chol
ate ci
tr
ate medi
a,col
orl
ess col
oni
es ar
e pr
oduced due t
o
nonl
act
osef
erment
ati
on.
Bi
ochemi
calReact
ions:
S.Ty
phif
erment
sgl
ucose,manni
tol
,mal
tosef
ormi
ngaci
dandgas.I
tdoesnot
f
ermentl
act
oseorsucr
oseanddonotpr
oduceI
ndol
e.MRposi
ti
ve,
VPnegat
ive,
cit
rat
e
posi
ti
ve-ur
easenegat
ive.
Ant
igeni
cSt
ruct
ure:
Theant
igensofSal
monel
l
aar
ecl
assi
fi
edi
nto3t
ypes.
i
. Fl
agel
l
arant
igen(
H–Ant
igen)
i
i
. Somat
ic(
or)Cel
lWal
lAnt
igen(
O–Ant
igen)
i
i
i. Sur
face(
or)Vi
rul
enceAnt
igen(
Vi–Ant
igen)
i
)H –Ant
igen:Fl
agel
l
arorH –ant
igeni
spr
esentont
hef
lagel
l
a.I
tisaheatl
abi
l
e
pr
otei
nandhel
psi
naggl
uti
nat
ion.Whenmi
xedwi
thant
iser
atheyaggl
uti
nat
erapi
dly
andf
orml
oose,
fluf
fycl
umpsofAg-Abcompl
exes.
i
i)O–Ant
igen:Somat
icorO–ant
igeni
saphosphol
i
pid–pr
otei
n–pol
ysacchar
ide
compl
ex.I
tisani
ntegr
alpar
tofcel
lwal
l
.Itwasf
ir
sti
sol
atedbyBoi
vi
n.Hencei
tis
al
socal
l
edasBoi
vi
nAnt
igen.Whenmi
xedwi
thant
iser
aO–Ant
igenf
orm compact
,
chal
kygr
anul
arcl
umps.
i
ii
)Vi
-Ant
igen:Somest
rai
nsofS.t
yphipossesssur
face(
K)ant
igensext
ernalt
othecel
l
wal
l
,ref
err
edt
oasVi
.Iti
saheatl
abi
l
eandt
heyar
enoti
nvol
vedi
ndi
agnosi
sbuthel
pful
i
nepi
demi
ologi
cal
typi
ngofS.t
yphi
byempl
oyi
ngVi
bact
eri
ophages.
Pat
hogenesi
s:
Sal
monel
l
acanf
oll
owoneoft
woi
nfect
ioncy
cles,asdepi
ctedi
nFi
g.Onecy
cle
l
eadst
oent
eri
ti
s,wher
east
heot
herl
eadst
oent
eri
cfev
er(
typhoi
d).
1.Ent
eri
ti
s:MostSal
monel
l
ast
rai
nscauseent
eri
ti
s.TheSal
monel
l
aei
nvadet
he
i
ntest
inal
wel
landpr
oduceent
erot
oxi
ns,
butt
her
eisnospr
eadi
ntot
hebl
ood.
Ent
eri
cFev
er(
Typhoi
d):

52
 Two Sal
monel
l
a ser
oty
pes – t
yphiand par
aty
phican cause t
yphoi
d. The
or
gani
smsi
nvadet
hewal
loft
het
ermi
nali
l
eum andt
henspr
eadt
othei
ntest
inal
l
ymphocy
tes,wher
ethey ar
e phagocy
tosed by PMNs and macr
ophages. Those
phagocy
tosedbymacr
ophagessur
viv
eandar
edi
ssemi
nat
edv
iat
hesecel
l
stoot
her
l
ymphoi
dti
ssues.Ev
ent
ual
l
y,t
heor
gani
smsescapet
hemacr
ophageandar
eli
ber
ated
i
ntot
hebl
ood,
wher
etheydi
ssemi
nat
ethr
oughoutt
hebody
.Ot
herSal
monel
l
aer
emai
n
wi
thi
nthe i
ntest
ine,wher
ethey i
nvade t
he gutwal
land may cause ul
cer
ati
on,
per
for
ati
onandhemor
rhage. Sal
monel
l
aeal
somul
ti
plywi
thi
nthegal
lbl
adderand
pey
er’
spat
ches.
PATHOGENESI
SOFENTERI
CFEVER:
Baci
l
lionr
eachi
ngt
hegutat
tacht
omi
crov
il
li
ofsmal
li
ntest
ineand
penet
rat
elami
napr
opr
iaandsubmucosa

Theyar
ephagocy
cosedbypol
ymor
phsandmacr
ophages

Baci
l
lir
esi
stsi
ntr
acel
l
ularki
l
li
ng,
ent
ermesent
eri
cly
mphnodes

Ent
eri
ntobl
oodt
hrought
hor
aci
cduct
sandcauset
ransi
entbact
eremi
a

Baci
l
liar
eseededi
nli
ver
,spl
een,
bonemar
row,
gal
lbl
adder
,ly
mphnodes,
Lungs,
kidneywher
efur
thermul
ti
pli
cat
iont
akespl
ace

Baci
l
li
cfr
om t
hesear
easar
eli
ber
atedi
ntot
hebl
oodcausi
ngmassi
ve
bact
eremi
awhi
chher
aldsonsetoft
hecl
i
nical
disease

Ent
eri
cfev
ert
yphoi
d

LABORATARYDI
AGNOSI
S:
- I
sol
ati
onofbaci
l
lif
rom pat
ient
- Demonst
rat
ionofant
i-
bodi
esi
nser
um
SPECI
MENS:

53
 1) Fi
rstWeek - Bl
oodcul
tur
e
Fr heendof1stweekt
om t o2ndweek - Wi
dal
test
2) Fr
om ear
ly st
age ofdi
sease upt
o
conv
alescence - Faccescul
tur
ebecomeposi
ti
ve
3) n2ndand3rdweekofi
I l
lness -
Ur
inecul
tur
ebecomeposi
ti
ve
Tr
eat
ment
:Ampi
ci
ll
i
n,amoxy
cil
l
in,f
urozol
i
dineandcot
ri
moxazol
ehav
ebeen
f
oundusef
uli
ntr
eat
mentoft
yphoi
dfev
er.
16.PSEUDOMONAS
Pseudomonasaer
ugi
nosa:
I
tisanoppor
tuni
sti
c,Gr
am negat
iver
odshapedpat
hogenwhi
chgi
vesbl
ueor
gr
eencol
ourt
othebur
nedt
issuebyt
hef
ormat
ionofpi
gment
sli
kepy
ocy
ani
nand
f
lur
escei
net
c.I
tispr
esenti
nsmal
lnumber
sini
ntest
ineofmanandal
soonhumanski
n.
Mor
phol
ogy
:
I
tisasl
enderGNB,1.
5–3m x0.
5m,nonspor
ing,noncapsul
ated,wi
tha
l
oosecapsul
e(gl
ycocal
yx)
.Gr
am negat
iver
od,act
ivel
ymot
il
ewi
th asi
ngl
epol
ar
f
lagel
l
um. Some st
rai
ns may pr
oduce mucoi
d col
oni
es. Thi
s mucus hav
ea
ext
racel
l
ularpol
ysacchar
isemadeupofal
ginat
epol
ymer
.
CULTURALCHARACTERS:
Obi
l
gat
eaer
obe, 6o–42oC.
Temp. Opt
.t 37oC,
emp. non-
fast
idi
ous.
NA - Di
ff
usi
blebl
uishgr
eenpi
gmenti
spr
oduced.Col
oni
eshav
eear
thyorgr
ape
l
i
keodour
.
MA - NLFcol
oni
es
BA - Pr
oduce-
haemol
yti
ccol
oni
es.
Br
oth - For
mssur
facepel
l
icl
e
PI
GMENTS:
a) Py
ocy
ani
n : Bl
uishgr
eenphenazi
nepi
gmentwhi
chi
ssol
ubl
einH2Oand
chl
orof
orm,
producedonl Ps.Aer
yby ugi
nosa.
b) Fl
uor
esci
n : Gr
eeni
shy
ell
ow pi
gmentwhi
chi
ssol
ubl
einwat
erbutnot
sol
ubl
einchl
orof
orm,
producedbymanyspeci
es.
c) Ot
herpi
gment
s : Theyar
epy
orubi
nandpy
omel
ani
n.

54
 BI
OCHEMI
CALREACTI
ONS:
OF - Oxi
dat
iveut
il
izerofGl
ucose
Sugar
s - notf
erment
ed
I
ndol
e - notpr
oduced
MR,
VP - Negat
ive
Ni
tr
ater
educt
ase - Posi
ti
ve,
[Ni
tr
it
efur
therr
educedt
oN2gas]
Cat
alase,
Oxi
dase,
argi
ninedi
hydr
olase - Posi
ti
ve
PATHOGENECI
TY:
Oneoft
hemostt
roubl
esomeagentwhi
chcausesnosocomi
ali
nfect
ions.
Local
i
sed i
nfect
ionsar
einf
ect
ionsofwounds,bed sor
es,ey
einf
ect
ion,UTI
f
oll
owedbycat
het
eri
zat
ion,bur
ninf
ect
ion.Postt
racheost
omypul
monar
yinf
ect
ion,
Nai
li
nfect
ionf
oll
owi
ngexcessi
veexposur
eofhandst
odet
ergent
sandwat
er.
Gener
ali
sedi
nfect
ionsar
emeni
ngi
ti
sfol
l
owedbyl
umbarpunct
ure,sept
icemi
a,
endocar
dit
isi
npat
ient
swi
thmal
i
gnancyorwi
thi
mmunosuppr
essi
vet
her
apy
.
Ot
her
srel
ated t
oinf
ant
il
e di
arr
hoea wher
e heat l
abi
l
e ent
erot
oxi
n was
demonst
rat
ed.
Shanghai
fev
err
esembl
i
ngt
yphoi
dfev
eri
s.
Cl
ini
calsy
ndr
omes

 Chr
oni
cpul
monar
yinf
ect
ioni
ncy
sti
cfi
brosi
s.
 Sept
icaemi
a,whi
chhasahi
ghmor
tal
i
tyandi
sapar
ti
cul
art
hreatt
oneut
ropeni
c
pat
ient
s.
 Rapi
dlypr
ogr
essi
vecor
neal
inf
ect
ionandot
it
isext
erna.
 Col
oni
zat
ionofbur
ns,
fol
l
owedbysept
icaemi
a.
 Ect
hymagangr
enosum,
adest
ruct
iveski
ncompl
i
cat
ionofbact
eraemi
a.
 Ost
eomy
eli
ti
s,sept
icar
thr
it
isandmeni
ngi
ti
s.

LABDI
AGNOSI
S:
Speci
mens:
Pus - woundi
nfect
ions
Swabs - bur
ninf
ect
ion
Bl
ood - Sept
icemi
a,endocar
dit
is

55
 Sput
um - Pneumoni
a
CSF - meni
ngi
ti
s
Cont
ami
nat
edf
lui
ds
Sel
ect
ivemedi
aused:
Cet
ri
mideagar
,Det
tol
orcer
tri
mideact
sasasel
ect
iveagent
.
CULTURALANDBI
OCHEMI
CALCHARACTERS:
(
Ref
erpr
evi
ouspage)
Cont
rol
:
 Const
antv
igi
l
ance,
str
ictat
tent
iont
oasepsi
s.
 Pr
eventhospi
tal
crossi
nfect
ion
 Tr
eat
mentofpr
edi
sposi
ngf
act
ors
 Speci
fi
cant
ibact
eri
alt
her
apy
Tr
eat
ment
:
Or
gani
smsar
eof
tenr
esi
stant
;ther
efor
e,t
reat
menti
sgui
dedbysuscept
ibi
l
iti
es.
Gent
amy
cin,
Car
beni
cil
l
in,
Pol
ymy
xinar
eef
fect
iveagai
nstPseudomonasaer
ugi
nosa.A
combi
-nat
ionofgent
amy
cinandcar
beni
cil
l
ini
susef
ulandcombi
neddr
ugt
her
apyby
car
beni
cil
l
inandami
nogl
ycosi
de.

1.VI
BRI
OCHOLERA
I
NTRODUCTI
ON:
I
tisanacut
edi
arr seasecausedbyVi
hoealdi bri
oChol
erae,char
act
eri
zedby
pr
ofusewat
erydi
arr
heaandv
omi
ti
ngl
eadi
ngt
ohy
pov
olemi
cshockanddeat
hin<
24hr
s.
Mor
phol
ogy
:V.Chol
eraei
sacomma–shaped,
cur
vedr
odmeasur
esabout1.

m x0.
2–0.
4m i
nsi
ze,
wit
hroundedends.
I
tisact
ivel
ymot
il
ebymeansofapol
arf
lagel
l
um.I
tshowsdar
ti
ngmot
il
it
y.
Theyr
eadi
l
yst
ainwi
thani
l
inedy
esandar
egr
am negat
ive.
Cul
tur
alChar
act
ers:
1.I
tgr
owswel
lonor
dinar
ymedi
a.
2.I
tisst
rongl
yaer
obi
c. I
tgr
owsi
nawi
der
angeoft
emper
at e16– 40oC
ur
(
opt
i ng37oC)andpH6.
mum bei 4–9.
6(opt
imum 8.
2)

56
 3.Gr
owt
hishi
ghi
nal
kal
i
nemedi
a.
4.Onnut
ri
entagarmedi
um,col
oni
esar
emoi
st,t
ransl
uscent
,measur
eabout1–
5mm di
amet
err
oundanddi
skl
i
ke.
5.Gr
owt
hshowschar
act
eri
sti
codour
.
6.On MaConkey
sagarmedi
um,onpr
olonged i
ncubat
ion,col
our
lesscol
oni
es
becomer
eddi
shduet
olakef
erment
ati
onofl
act
ose.
7.V.Chol
eraegr lonThi
ow wel osul
phat
eCi
tr
atebi
l
esucr
ose(
TCBS)agar
.They
oducey
pr ell
owcol
oni
esoni
t.
8.OnBl
oodagarmedi
um,col
oni
esar
esur
roundedbyagr
eenzonewhi
chl
ater
t
urnscl
earduet
ohemodi
gest
ion.
9.I
ngel
ati
onst
abcul
tur
einf
undi
bul
i
for
mli
quef
act
ionoccur
swi
thi sat22oC.
n3day
10.
Inpept
onewat
ergr
owt
hoccur
satt
hesur
faceasapel
l
icl
e.
11.A numberofspeci
almedi
aar
eempl
oyedf
ort
hecul
ti
vat
ionof
,V.Chol
erae.
Theyar
eVRmedi
um,
car
y–Bl
airmedi
um,
Alkal
i
nebi
l
esal
tagar(
ABSA)medi
um,
GTTA,
TCBSmedi
um et
c.
Bi
ochemi
calr
eact
ions:
1.Fer
ment
s(CHO)
npr
oduci
ngaci
dbutnogas.
2.I
ndol
e+v
e,ni
tr
ali
sar
ereduced.
3.Cat
alaseandOxi
dase+v
e
4.Met
hyl
redandur
easet
est
sar
e–v
e
5.Gel
ati
nisl
i
quef
ied
Ant
igeni
cSt
ruct
ure:
Theor
gani
sm i
ssubdi
vi
dedbyt
hesomat
icOant
igens;O1andO139bei
ngt
hemai
n
t
ypesassoci
atedwi
thchol
era.Theyar
eabl
etosur
viv
ethegast
ri
caci
dit
y,bur
rowi
ng
t
hrough t
he i
ntest
inalmucus t
o at
tach t
oint
est
inalepi
thel
i
alcel
l
svi
athe GM1
gangl
i
osi
deandpr
oduceamul
ti
mer
icpr
otei
ntoxi
n(chol
erat
oxi
n),whi
chst
imul
ates
adeny
lcy
clase wi
thi
nthe ent
eri
c cel
l
s,r
esul
ti
ng i
nthe secr
eti
on ofwat
erand
el
ect
rol
ytesi
ntot
hel
umenoft
hebowel
.

Cl
assi
fi
cat
ion:
Twobi
oty
pesofV.Chol
eraar
ecl
assi
candEl
Tor
.
Thesear
ecl
assi
fi
edi
nto3ser
oty
pesOgawa,
InabaandHi
koj
i
ma.

57
SOURCESOFI
NFECTI
ON:Pat
ientorcar
ri
ers
Car
ri
ersmaybei
ncubat
ory
,conv
alescent
,heal
thyorchr
oni
ccar
ri
ers.
Conv
alescent
sexcr
eteVi
bri
osi
nfaecesf
or2-
3weeks.
Chr
oni
ccar
ri
ersshedbaci
l
lif
ormont
hsory
ear
s.
Heal
thycar
ri
ersshedf
or10day
s.
MODEOFI
NFECTI
ON:
 Faecoor
alr
out
e,i
nfect
ionacqui
redt
hroughcont
ami
nat
edf
oodorwat
er.
 Hand cont
ami
nat
ion ofst
ored dr
inki
ng wat
eri
s an i
mpor
tantmet
hod of
domest
icspr
eadofi
nfect
ion.

PATHOGENESI
S:
 Vi
bri
os ent
eror
all
ythr
oughcont
ami
nat
ed f
oodand wat
er. Theyar
ehi
ghl
y
suscept
ibl
etoaci
dsandgast
ri
caci
dit
ypr
ovi
desanef
fect
ivebar
ri
eragai
nst
smal
ldosesofChol
eraVi
bri
os.
 I
nsmal
lint
est
inet
heyar
eabl
etocr
osst
hepr
otect
ivel
ayerofmucusandr
each
t
heepi
thcl
i
alcel
l
sbychemot
axi
s,mot
il
it
y,muci
naseandpr
oteol
yti
cenzy
mes.
 Adhesi
ont
otheepi
thel
i
alsur
faceandcol
oni
zat
ionmaybef
aci
l
itat
edbyspeci
al
f
imbr
ia such as Toxi
n Conj
ugat
ed Pi
l
us (
TCP)
. Thr
oughoutt
he cour
se of
i
nfect
i Vi
on, br
iosr
emai
nat
tachedt
otheepi
thel
i
um butdonotdamageori
nvade
t
hecel
l
s.
 Theyel
i
citaent
erot
oxi
ncal
l
edChol
eraToxi
n(CT)whi
chi
sver
ysi
mil
art
oheat
Labi
l
eToxi
n(I
.T)ofE.Col
iin st
ruct
ural
,chemi
cal
,bi
ologi
caland ant
igeni
c
pr
oper
ti
es,
thoughCTi
smor
epot
entt
hanLT.
 CTi
sdet
ermi
nedbychr
omosomal
genes.
 I
tsmol
ecul
arwei
ghti
s84,
000.
 I
thasone‘
A’andf
ive‘
B’subuni
ts.

CLI
NICALMANI
FESTATI
ONS:
Lossofl
argev
olumeofdi
arr
hoealf
lui
dwhi
chappear
s‘r
icewat
ery
’,wi
thf
lecksof
mucusi
ncol
our
lessf
lui
d.St
ool
hasf
ishyodour
.
Vomi
ti
ngst
art
swi
thdi
arr
hoeai
scopi
ous,
cont
aini
ngcl
earf
lui
d.

58
 Lossoff
lui
dleadst
ohemo-
concent
rat
ion,
hypokal
emi
a,aci
dosi
sshock.
Compl
i
cat
ions ar
e muscul
arcr
amps,r
enalf
ail
ure,pul
monar
y oedema,
car
dial
ar
rhy
thi
mia,
par
aly
tici
l
euset
c.
LABDI
AGNOSI
S:
Speci
men: St
oolcol
l
ect
ed dur
ing t
he acut
e st
age of t
he di
sease bef
ore
admi
nist
rat
ionofant
ibi
oti
cs.I
tiscol
l
ect
edbyi
ntr
oduci
ngr
ubbercat
het
erl
ubr
icat
ed
wi
thpar
aff
ini
ntot
her
ect
um andl
ett
ingt
hest
oolf
low i
ntot
hescr
ew capped
cont
ainer
.
TRANAPORTMEDI
Ausedar
e
Venkat
raman–Ramakr
ishnanmedi
um cont
ainsseasal
t&pept
onepH8.
6.8.
8
Car
y-Bl
airMedi
um buf
fer
edsol
uti
onofNaCl
2,Nat
hiogl
ycol
l
ate,
CaCl
2pH8.
4
Al
kal
i
nepept
onewat
er(
APW)pH8.
6.

Pr
event
ionandcont
rol

 Saf
ewat
ersuppl
i
esar
ethemai
nst
ayofpr
event
ion.
 Communi
tyeducat
ionr
educesspr
ead.
 Exper
iment
all
i
veat
tenuat
edandsubuni
tvacci
nesar
eundert
ri
al.

TREATMENT:
 Pr
omptandadequat
erepl
acementofwat
erel
ect
rol
ytesbyor
aladmi
nist
rat
ionof
sol
uti
oncont
aini
nggl
ucoseandel
ect
rol
ytesei
theral
oneorsuppl
ement
edwi
th
i
ntr
avenousf
lui
ds.
 Or
alt
etr
acy
cli
ner
educest
heper
iodofv
ibr
ioexcr
eti
on.
 Mul
ti
pledr
ugr
esi
stantst
rai
nsar
ecommon.

 Or
alr
ehy
drat
ionsol
uti
on(
sal
tandgl
ucosemi
x).
 I
ntr
avenousf
lui
dsf
orsev
erecases.
 Tet
racy
cli
neorci
prof
loxaci
ncanshor
tent
hedur
ati
onandr
educet
hesev
eri
ty.

19.SHI
GELLADYSENTERI
AE

59
 Themember
sofgenusShi
gel
l
aar
eimpor
tantcausat
iveagent
sofbaci
l
lar
y
dy
sent
eryi
nhumanbei
ngs.Thedy
sent
erybaci
l
libel
ongt
othegenus‘
Shi
gel
l
a’,named
af
ter‘
Shi
ga’who i
sol
ated t
he f
ir
stmemberoft
he gr
oup i
n 1896 f
rom epi
demi
c
dy
sent
eryi
nJapanwhi
chwast
hencal
l
ed‘
Shi
gel
l
aShi
ga’andi
snow knownasSh.
Dy
sent
eri
aet
ype–I
.
Mor
phol
ogy
:Shi
gel
l
aear
enonspor
ing,noncapsul
ated,nonf
lagel
l
ated,non
mot
il
e,gr
am negat
ive,aer
obi
cbaci
l
li
,whi
chmeasur
ear
ound1–3m x0.
5m.The
or
gani
smsofgenusShi
gel
l
adi
ff
erf
rom ot
herEnt
erobact
eri
aceaei
nthatt
heyar
e
excl
usi
vel
ypar
asi
tesofhumani
ntest
ineandot
herpar
asi
tes.
Cul
tur
alChar
act
ers:
Gr
owt
hRequi
rement
s:Shi
gel
l
aor
gani
smsar
eaer
obi
candf
acul
tat
iveanaer
obi
c.
Theycangr
ow ov
erawi
der
angeoft
emper
atur
ebutopt
imalgr
owt
htemper
atur
eis
37oC.Theycangr
owonor
dinar
ymedi
apr
ovi
dedgl
ucoseandni
cot
ini
candar
eadded
t
othemedi
um.
Col
onyChar
act
ers:Onsi
mpl
emedi
asuchasnut
ri
entagarandbl
oodagar
,
col
oni
esmeasur
e2– 3mm i
ndi
amet
er. Thesear
esmoot
h,gr
ayi
shorcol
our
less,
t
ransl
ucentcol
oni
es.
OnMacConkeyagar
,col
oni
esar
epal
e. I
nDeoxy
chol
ateci
tr
ateagarmedi
um
col
our
lesscol
oni
esar
epr
oduced.Theydonotgr
owonWi
l
sonandBl
air
’smedi
um.I
n
Shi
gel
l
a–Sal
monel
l
aagar(
S.Sagar
)thecol
oni
esar
ecol
our
less.
I
nli
qui
dmedi
a(Pept
onewat
erandnut
ri
entbr
oth)shi
gel
l
aegi
ver
iset
ouni
for
m
t
urbi
dit
y.
Bi
ochemi
calReact
ions:
Thesear
eoxi
dasenegat
iveandf
ermentgl
ucosewi
thaci
dpr
oduct
ion,nogas
anddonotf
ermentsal
i
cinandl
act
ose. Ont
hebasi
sofbi
ochemi
calr
eact
ions,t
he
genushasbeendi
vi
dedi
ntof
ourgr
oupsA,
B,CandD.Shi
gel
l
aear
enotconsi
der
edv
ery
r
esi
stantor
gani
sms.Thesear
edest
roy stheatat55oCi
edbymoi nlesst
hanonehour
phenol
(1%)ki
l
lsi
tin15mi
nut
es.
Ant
igeni
cSt
ruct
ure:
Based on “
O”ant
igens (
Somat
ic ant
igens)Shi
gel
l
ae ar
e di
ff
erent
iat
ed i
nto
ser
oty
pes,i
dent
if
iedbyaggl
uti
nat
ionabsor
bedant
iser
a.Theant
igeni
cst
ruct
ureoft
he

60
Shi
gel
l
aei
scompl
ex.S.dy
sent
eri
aeconsi
stsof12ser
oty
pes,ofwhi
chser
oty
pe1i
s
al
soknownas“
Shi
ga’
sbaci
l
lus”andser
oty
pe2as“
Schi
mit
zbaci
l
lus”andsur
face(
k)
ant
igensar
eal
sof
ound.
Pat
hogenesi
s:
Shi
gel
l
aei
nfectmanandot
herpr
imat
es.Thei
nfect
ingdosei
ssmal
l
,bet
ween10
and100or
gani
smsandi
tcausesdy
stent
ery
.Thedy
sent
eryi
sloosel
yusedt
omean
di
arr
hoeawi
thpassageofpusbl
oodandormucousi
nthest
oolaccompani
edby
abdomi
nal
crampsandt
enesmus.
Fol
l
owi
ngi
ngest
ion,t
heShi
gel
l
aear
eusual
l
yunabl
etopenet
rat
ethei
ntest
ine
i
ntot
hedeeperbodyt
issuesori
ntot
hebl
ood,butmul
ti
plyi
nthesmal
lint
est
ine.The
bact
eri
aar
emechnani
cal
l
ycar
ri
edt
othel
argei
ntest
ine.
Thepr
imar
yst
epi
nthedi
seasepr
ocessi
sthei
nvasi
oni
ntot
hecel
l
soft
he
col
oni
cepi
thel
i
um byt
hepat
hogen.Tor
eacht
heepi
thel
i
alcel
l
s,t
heor
gani
sm must
t
ransv
ersebot
hthemucousandgl
ycocal
yxl
ayer
s,whi
chcoatt
heepi
thel
i
um. On
comi
ngi
ncont
actwi
tht
hecol
oni
cint
est
inalepi
thel
i
um,
thebact
eri
um i
sengul
fedbyan
i
nvagi
nat
ionoft
hecel
lmembr
ane. Af
teri
nvasi
on,t
hepat
hogeni
sobser
vedi
na
v
acuol
e(consi
sti
ngofhostcel
lmembr
ane)wi
thi
ntheepi
thel
i
alcel
l
. Ly
sisoft
he
v
acuol
e pr
ecedes mul
ti
pli
cat
ion and i
nter
cel
l
ularspr
ead oft
he or
gani
sms. The
or
gani
smsspr
eadt
hroughoutt
hecy
topl
asm andi
nvadeandadj
acentcel
lthr
ough
l
ater
almembr
ane.Ther
esul
toft
hispr
ocessi
sthef
ormat
ionoful
cer
sthr
oughwhi
ch
bl
oodandi
nfl
ammat
orycel
l
sreacht
hel
umenoft
hei
ntest
ine.Shi
gel
l
aet
hatr
eacht
he
l
ami
napr
opr
iaev
okeani
ntensei
nfl
ammat
oryr
eact
ionandr
arel
ypenet
rat
efur
thert
o
submucosa.Thei
ntest
inal
ulcer
ati
oni
sduet
otheact
ivi
tyoft
hebact
eri
alendot
oxi
n.
I
nfl
ammat
ion,t
oget
herwi
thsl
oughi
ngoft
heepi
thel
i
alcel
l
s,r
esul
tsi
nul
cer
ati
ve
l
esi
ons. Af
ter1-
3 day
sofi
ncubat
ion,t
hepat
ientexper
iencesasuddenonsetof
sy
mpt
omsabdomi
nalcr
amps,f
everanddi
arr
hoea. Thedi
arr
hoealst
oolf
requent
ly
cont
ainsbl
oodandmucous.I
nfect
ionduet
oS.dy
sent
eri
aei
sal
way
smor
eser
ious.
Labor
ator
yDi
agnosi
s:
A.Speci
mens:a)Formi
croscopyandcul
tur
e,f
reshst
ool
,mucousf
lakes,r
ect
al
swabsar
ecol
l
ect
edunderasept
icpr
ecaut
ion.
b)Bl
ood,ser
um maybeex
ami
nedf
ordemonst
rat
ionofr
isi
ngt
it
reofaggl
uti
nin

61
ant
ibodi
es.
B.Mi
croscopi
cExami
nat
ion:Cov
ersl
i
ppr
epar
ati
oni
nsal
i
neandi
odi
neshows
l
argenumberofpuscel
l
swi
thdegener
atednucei
,RBCandmacr
ophageswi
thf
ewnon
mot
il
ebact
eri
aduet
oShi
gel
l
ae.Gr
am st
aini
ngi
sofnouse
C.Cul
tur
e:Medi
a
a)MacConkey
’sagar
b)DCA
c)S–Sagar
d)Sel
eni
teFbr
oth
Al
oopf
ulofmat
eri
ali
sinocul
atedonsel
ect
ivemedi
ali
keMacConkey
’sagaror
S.
Sagarmedi
a.Sel
eni
te–Fbr
oth(
0.4%)i
susedasenr
ichmentandt
ranspor
tmedi
um
whi
chper
mit
srapi
dgr
owt
hofent
eri
cpat
hogenswhi
l
etempor
ari
l
y(f
or9– 12hr
s)
i
nhi
bit
ingt
hegr
owt
hofE.col
ior
gani
smsf
rom Sel
eni
te-
Fbr
othar
esubcul
tur
edi
n
MacConkey
’sagaraf
ter24hr
sincubat
ionat37oC.
Col
our
lesscol
oni
esappearonMacConkey
’sagarmedi
um af
ter12t
o18hr
s.
i
ncubat
ionwhi
char
efur
thert
est
edbysmearexami
nat
ion,mot
il
it
ypr
epar
ati
onand
bi
ochemi
cal
react
ions-Shi
gel
l
aear
eGr
am-
negat
ivenon-
mot
il
ebaci
l
li
.
Pr
event
ion:Nov
acci
nei
sav
ail
abl
e.Shi
gel
l
osi
sispr
event
edbymai
ntai
ninga
pot
abl
e wat
ersuppl
y,washi
ng hands,br
east
-f
eedi
ng i
nfant
s,and i
dent
if
ying and
t
reat
inghumancar
ri
ers.
Tr
eat
ment
:Nospeci
fi
cther
apyi
sav
ail
abl
e.Di
ff
erentst
rai
nsofShi
gel
l
aedi
ff
eri
n
t
hei
rant
ibi
oti
csensi
ti
vi
tyt
o commonl
yused agent
s. Adul
tsmayr
ecov
erwi
thout
ant
ibi
oti
cs,
butt
heymayr
equi
rer
ehy
drat
ion.

22.My
cobact
eri
um Lepr
ae
MORPHOLOGY:
Theyar
est
rai
ghtorsl
i
ght
lycur
vedr
od,cl
ubbedf
orms,br
anchi
ngf
ormsmaybe
abser
ved.I
tisG(
+)i
ve.I
tisl
essaci
dfastt
hant
uber
clebaci
l
liandhence5%H2SO4i
s
usedf
ordecol
ori
zat
ion.
Li
vebaci
l
liappearsol
i
d and uni
for
mlyst
ained,wher
easdead baci
l
liappear
f
ragment
edandgr
anul
ar.Baci
l
liar
eseensi
ngl
yori
ngr
oupsi
ntr
acel
l
ular
lyorl
yi
ngf
ree

62
out
side.Massesofbaci
l
liboundt
oget
herbyal
i
pidl
i
kesubst
ancecal
l
edgl
i
aar
eknown
asgl
obi
.Gl
obiappearwi
thi
nlar
geundi
ff
erent
iat
edhi
sti
ocy
tescal
l
edv
irehowsl
epr
aor
f
oamycel
l
s.
CULTI
VATI
ON:
- ¬Donotgr
owonbact
eri
ologi
cal
medi
aort
issuecul
tur
es.
- Theycoul
dmul
ti
plyi
nf cekeptat20oC.
eetpadsofmi
- Ni
ne-
bandedar
madi
l
loi
shi
ghl
ysuscept
ibl
etoi
nfect
ion.
- Gener
ati
ont
imeofl
epr
abaci
l
lusi
s12-
13day
s.
PATHOGENESI
S:
- Tar
getcel
l
sar
eSchwanncel
l
sandr
esul
ti
ngner
vedamagei
sresponsi
blef
ort
he
mai
ncl
i
nicalf
eat
uresofl
epr
osyi
.e.anaest
hesi
aandmuscl
epar
aly
sis.Repeat
ed
i
njur
yandi
nfect
ionsofanaest
het
icext
remi
ti
esl
eadt
othei
rgr
adual
dest
ruct
ion.
- I
nfi
l
trat
ionofski
nandcut
aneousner
vesbybaci
l
lil
eadst
ofor
mat
ionofv
isi
ble
l
esi
ons,
oft
enwi
thpi
gment
edchanges.
- Fi
rstsi
gnofl
epr
osyi
sanonspeci
fi
cski
nreact
ionwhi
chheal
sspont
aneousl
y.I
f
t
he di
sease pr
ogr
ess, i
ts cl
i
nical mani
fest
ati
on i
s det
ermi
ned by t
he
i
mmunol
ogi
calr
esponseoft
hepat
ientt
othebaci
l
lusandspect
rum mayv
ary
f
rom t
uber
cul
oid(
TT)t
olepr
omat
ous(
LT)t
ype.
Ri
del
yandJopl
i
ngcl
assi
fi
edt
hespect
rum ofl
epr
osyi
ntof
ivegr
oups
(
1)Tuber
cul
oid(
TT)
,(2)Bor
der
li
ne t
uber
cul
oid(
BT)
,(3)Bor
der
li
ne (
BB)
,(4)
Bor
der
li
nel
epr
omat
ous(
BL)
,(5)Lepr
omat
ous(
LL)
.

3)Bor
der
li
neTy
pe:Ref
erst
olesi
onspossessi
ngchar
act
ersofbot
htuber
cul
oidand
l
epr
osyl
epr
omat
oust
ype.I
tmayshi
ftt
otuber
cul
oidorl
epr
omat
oust
ype,dependi
ng
onchemot
her
apyandal
ter
nat
ionsi
nhostr
esi
stance.
4)I
ndet
ermi
nat
eTy
pe:I
tisanear
lyunst
abl
ereact
ionswhi
chi
snotchar
act
eri
sti
cof
ei
therbor
der
ingort
uber
cul
oidt
ype. I
nmanyi
tunder
goesspout
aneousheal
i
ng. I
n
ot
her
s,i
tmaypr
ogr
esst
otuber
cul
oidorl
epr
omat
oust
ype.
LABDI
AGNOSI
S:
- I
tconsi
stsofdemonst
rat
ionofAFBi
nlesi
ons.
- Speci
mensar
ecol
l
ect
edf
rom

63
 (
1)Nasal
mucosa(
2)Ski
nlesi
ons(
3)Carl
obes
NasalMucosa:I
tshoul
dbecol
l
ect
edbyi
ntr
oduci
ngbl
untscal
peli
ntonoseandi
nter
nal
sept
um t
oremov
eapi
eceofmucusmembr
anewhi
chi
steasedt
ofor
m auni
for
m
smearonsl
i
de.
Ski
nSampl
esshoul
dbeobt
ainedf
rom t
heedgeoft
hel
esi
onbycut
ti
ngusi
ngascal
ped
deepenought
ogeti
ntot
hei
nfi
l
trat
edl
ayer
s.Scr
apet
hesi
desandbot
tom oft
hecutso
ast
oobt
ainl
i
ttl
eti
ssuepul
pwhi
chi
ssmear
eduni
for
mlyonsl
i
de.
Si
tes t
hatshoul
d be sampl
ed ar
e at
least5-
6 di
ff
erentar
eas i
ncl
udi
ng ski
n ov
er
but
tocksf
orehead,
chi
n,cheeksandear
s.
St
aini
ngcol
dst
aini
ngbyGabbet
smet
hod

23.TREPONEMAPALLI
DUM

I
NTRODUCTI
ON:
I
tisav
ener seasecausedbyTr
ealdi eponemaPal
l
idum,
aspi
rochaet
e.Thename
‘
Syphi
l
is’
wasder
ivedf
rom shepher
dnamedSy
phi
l
uswhohadbeenst
ruckf
ir
stwi
tht
he
di
sease.
T.Pal
l
idum i
saSpi
rochet
e(Spei
ra=coi
l
;chai
te=hai
r)whi
char
eel
ongat
ed,mot
il
e,
f
lexi
ble,spi
ralbact
eri
a hav
ing endof
lagel
l
a. Spi
rochet
es bel
ong t
othe or
der–
Spi
rochet
aleshav
ingt
wof
ami
l
iesi
nit
.
1)Spi
rochet
acease -
- hav
e4gener
a
(
i)Spi
rochaet
a
(
ii
)Cr
ist
ispi
ra
(
ii
i)Tr
eponema
(
iv)Bor
rel
i
a
2)Lept
ospi
racease -
- hav
eonl
yonegenus
(
i)Lept
ospi
ra
Amongt
hesegener
a,Tr
eponema,
Bor
rel
i
aandLept
ospi
raar
ehumanpat
hogens.
Tr
eponemes (
trepos = t
otur
n and nema = t
hread)as r
elat
ivel
y shor
t,sl
ender
spi
rochet
es.
T.Pal
l
idum has4subspeci
esi
nit
.

64
 1.T.Pal
l
idum -
- causesSy
phi
l
is
2.T.Per
tenue -
- causesYaws
3.T.car
ateum -
- causesPi
nta
4.T.endemi
cum -
- endemi
cSy
phi
l
is
T.Pal
l
idum wasdi
scov
eredbySchaudi
nnandHof
fmann(
1905)i
nthechanchr
es
andi
ngui
nal
lymphnodesofsy
phi
l
icpat
ient
s.
Mor
phol
ogy
:
T.Pal
l
idum i
sat
hin,del
i
cat
e spi
rochet
e,sl
enderf
il
ament
ous hel
i
ces wi
th
t
aper
ingends,about10m i
nlengt
h(r
ange6–m)and0.
1–0.
2m wi
dthev
enl
y
spacedcoi
l
s.I
thasabout10r
egul
arspi
ral
swhi
char
eshar
pandangul
aratr
egul
ar
i
nter
val
sofabout1m.
I
tisact
ivel
ymot
il
e,exhi
bit
ing r
otat
ing ar
ound t
hel
ong axi
s,backwar
d and
f
orwar
d.I
tcannotbeseenundert
hel
i
ghtmi
croscopei
nwetf
il
msbutcanbeseenby
negat
ivest
aini
ngUl
tr
ast
ruct
ural
l
y,T.Pal
l
idum i
schar
act
eri
sedbyat
ermi
nalknobl
i
ke
st
ruct
ure.3or4endof
lagel
l
aor
igi
nat
efr
om eachendoft
hecel
l
,mov
eal
ongt
heaxi
al
aspectandi
nter
digi
tat
eati
tscent
re.
Cul
tur
alChar
act
ers:
Pat
hogeni
ctr
eponemesdonotgr
owi
nar
ti
fi
cialcul
tur
emedi
a.Li
mit
edgr
owt
his
r
epor
tedi
nti
ssuecul
tur
ecel
l
s.T.pal
l
idum gr
owsoncompl
exmedi
aunderanaer
obi
c
condi
ti
ons.Theyr
emai
nmot
il
eandv
irul
entf
or10–12day
sont
hosemedi
a.Theyar
e
al
socul
tur
edbyser
ialt
est
icul
arpassagei
nrabbi
ts.Rei
terst
rai
nofTr
eponemegr
ows
wel
lont
higl
ycol
l
atemedi
um cont
aini
ngser
um.Thesear
enonpat
hogeni
candshow
mor
phol
ogi
cal
andant
igeni
csi
mil
ari
ti
eswi
thT.pal
l
idum.
Ant
igeni
cSt
ruct
ures:
Theant
igeni
cst
ruct
ureofT.pal
l
idum i
scompl
ex.Ther
ear
emai
nly3t
ypesof
ant
igensdet
ect
edi
nit
.
1.Car
diol
i
pinAnt
igen(
Lipi
dhapt
en)orWasser
manAnt
igen
2.Gr
oupAnt
igen
3. Speci
esSpeci
fi
cAnt
igen
1.Car
diol
ipi
nAnt
igen:I
tisal
i
pidhapt
enandi
tischemi
cal
l
yadi
phosphat
idy
l
gl
ycer
ol.Theant
ibodi
esagai
nstt
heseant
i eknownasReagi
gensar nAnt
ibodi
es.These

65
Ant
ibodi
esar
etest
edordemonst
rat
edf
orsy
phi
l
i nWasser
si mann,KahnandVDRL
t
est
s.I
ntheset
est
s,ahapt
enext
ract
edf
rom beefhear
tisusedast
heant
igen.
2.Gr
oupAnt
igen:I
tisf
oundi
nT.pal
l
idum aswel
lasi
nnonpat
hogeni
ccul
tur
abl
e
t
reponemessuchasRei
terTr
eponeme.
3.Speci
es Speci
fi
c Ant
igen:I
tis pol
ysacchar
ide i
n nat
ure. The ant
ibodi
es
dev
elopedagai
nsti
tar
edemonst
rat
edbyt
hespeci
fi
c.T.pal
l
idum t
est
swhi
chgi
ves
posi
ti
ver
esul
tswi
thser
aofi
nfect
edpat
ient
swi
thpat
hogeni
ctr
eponemes.
Pat
hogenesi
s:A.Sy
phi
l
isnat
ural
l
yoccur
sonl
yinhumanbei
ngs.
PATHOGENESI
S:
ModeofI
nfect
ion:I
tisacqui
redbysexualcont
act
,thespi
rochaet
eent
erst
he
bodyt
hroughmi
nut
eabr
asi
onsont
heski
normucosa.
I
nfect
ivi
tyi
shi
ghestdur
ingt
hef
ir
st2y
ear
soft
hedi
sease–t
hepr
imar
yandt
he
ear
lyst
ages.
I
D50=50t
reponemes I
Cper
iod=1mont
h(10-
90day
s)
CLI
NICALMANI
FESTATI
ON:
I
thas3st
agesnamel
ypr
imar
y,secondar
y,l
atentsy
phi
l
isandt
ert
iar
yst
age.
Pr
imar
ySy
phi
li
s:
 I
tischar
act
eri
sedby‘
chancr
e’whi
chi
sseenongeni
tal
s,somet
imesonmout
h
andni
ppl
es.
 I
tisapai
nless,av
ascul
ar,ci
rcumscr
ibedi
ndur
atedandsuper
fi
cial
l
yul
cer
ated
l
esi
oncal
l
edhar
dchancr
e.
 I
tiscov
eredbyat
hick,
glar
y,exudat
esr
ichi
nspi
rochaet
es.
 Ev
enbef
oret
hechancr
eappear
s,t
hespi
rochaet
esspr
eadt
oregi
onall
ymph
nodes(
whi
chbecomesi
ndur
ated,swol
l
en,r
ubber
yandnon-
tender
)andt
othe
bl
ood.
 Per
soni
sinf
ect
ious.
 I
theal
sin40day
sleav
ingat
hinsear
.
Secondar
ySy
phi
li
s:
 I
tset
sin2-
6mont
hsaf
terpr
imar
ychancr
e.
 I
tisduet
owi
despr
eadmul
ti
pli
cat
ionofspi
rochaet
esandt
hei
r di
ssemi
nat
ion
t
hroughbl
ood.

66
  Papul
arski
nrash,mucouspat
chesi
ntheor
ophar
ynxandcondy
lomat
aatt
he
mucocut
aneousj
unct
ionsar
echar
act
eri
sti
cs.
 Per
soni
shi
ghl
yinf
ect
ious.
 Ther
emaybeosseous,
meni
ngeal
andopht
hal
mici
nvol
vement
.
Lat
entSy
pil
is:
 I
tist
heper
iodofqui
escencebet
weent
heappear
anceofsecondar
yandst
artof
t
ert
iar
ysy
phi
l
is.
 Di
agnosi
spossi
bleonl
ybeser
ologi
cal
test
.
 Thi
smaybef
oll
owedbynat
uralcur
eori
nsomemani
fest
ati
onsoft
ert
iar
y
sy
phi
l
isoccur
.
Ter
ti
arySy
phi
li
s:
 I
tconsi
stsofanscur
ysms,chr
oni
cgr
anul
omat
a(gummat
a),meni
ngi
ovacul
ar
mani
fest
ati
on.
 I
nfew cases l
atet
ert
iar
yorquar
ter
nar
ysy
phi
l
is consi
sti
ng ofneur
ologi
cal
mani
fest
ati
onssuchasTabesdor
sal
i
sorgener
alpar
aly
sisoft
hei
nsaneoccur
s.
NONVENEREALSYPHI
LIS:
 Acqui
redoccupat
ional
l
ybydoct
ors,
nur
seswhi
l
eexami
ningt
hepat
ient
s.
 Sameasv
ener
eal
syphi
l
is,
butt
hepr
imar
ychancr
eisext
rageni
tal
.
CONGENI
TALSYPHI
LIS:
 I
nfect
iont
ransmi
tt
edf
rom mot
hert
oof
fspr
ingt
ranspl
acent
all
y.
 Abor
ti
ons,st
il
lbi
rt
hs,f
oll
owedbyl
i
vebi
rt
hsofi
nfant
swi
tht
hest
igmaofsy
phi
l
is
ar
ethef
eat
ures.
LABORATORYDI
AGNOSI
S:
Thi
sisnecessar
yduet
othef
oll
owi
ngr
easons
1.Mani
fest
ati
onsar
evar
iabl
e.
2.Pr
esenceofasy
mpt
omat
icper
iodsdur
ingdi
sease.
3.Hel
pst
oassesst
hecur
eaf
tert
reat
ment
.
I
tconsi
stsof(
1)demonst
rat
ionofspi
rochaet
esbymi
croscopy(
2)demoof
ant
ibodi
esi
nser
um.
Tr
eat
ment
:
I
n1909,
Paul
Ehr
li
chi
ntr
oducedanar
seni
cder
ivat
ive,
arsphenami
neorsal
var
san,

67
ast
her
apy
.Peni
cil
l
ini
suni
for
mlyef
fect
ivei
nsy
phi
l
is.Asi
ngl
einj
ect
ion2.
4mi
l
li
on
uni
tsofBenzat
hinePeni
cil
l
inGi
sadequat
einear
lycases.Forl
atesy
phi
l
ist
hisdosei
s
r
epeat
ed weekl
yfor3 weeks. I
n pat
ient
s al
l
ergi
cto Peni
cil
l
in,er
ythr
omy
cin or
t
etr
acy
cli
nei
sused.I
nneur
osy
phi
l
iscer
tri
axonei
sef
fect
ive.
25.RI
CKETTSI
AE

I
NTRODUCTI
ON:
Theyar
esmal
lGr
am negat
ivebaci
l
liadapt
edt
oobl
i
gat
eint
racel
l
ularpar
asi
ti
sm.
Theyar
epr
imar
il
ypar
asi
tesofar
thr
opodv
ect
orssuchasf
leas,mi
tes,t
icks,l
ouseet
c.
wher
etheyf
oundi
nal
i
ment
arycanal
.Inv
ert
ebr
atesi
ncl
udi
nghumans,t
heyi
nfect
v
ascul
arendot
hel
i
um andr
eti
cul
oendot
hel
i
alcel
l
s.

CLASSI
FICATI
ON:

Fami
l
y - Ri
cket
tesi
aceae
Gener
a I Ri
cket
tsi
a Ty
phusf
evergr
oup
Spot
tedf
evergr
oup
Scr
ubt
yphusgr
oup
TYPHUSFEVERGROUP:

a) Rockymount
ainspot
tedf
ever - R.Ri
cket
tsi
b) I
ndi
ant
ickt
yphus - R.Conor
i
c) Si
ber
iant
ickt
yphus - R.Si
ber
ica
d) Queensl
andt
ickt
yphus - R.Aust
ral
i
s
e) Ri
cket
tsi
alpox - R.Akar
i
R.Tsut
sugamushi
SCRUBTYPHUS:

GenusI
I Rochal
imaea
Speci
es - Rochal
i
maeaQui
ntana–t
renchf
ever
GenusI
II Coxi
ell
a
Speci
es - C.Bur
net
ti–‘
Q’(
Quer
y)f
ever

68
 GenusI
V - Ehr
li
chi
a
Speci
es - E.
Sennet
su–Sennet
suf
ever
MORPHOLOGY:
Pl
eomor
phi
c coccobaci
l
li0.
3 – 0.
6 m x 0.
8 –2m;non-
mot
il
e and non-
capsul
atedexceptR.Pr
owazeki
.
Gr
am Posi
ti
ve,
butdonott
akest
ainwel
l
.
Gi
emsaSt
aini
ng–t
heyst
ainbl
uishpur
ple
Machi
avel
l
oandGi
menez–St
aini
ng–deepr
ed
CULTI
VATI
ON:
- Donotgr
owoncel
lfr
eemedi
a.
- Seeni
ncy
topl
asm ofi
nfect
edcel
l
s,spot
tedf
everagent
sseeni
nnucl
eusal
so.
- Yol
ksac,
chi
ckembr
yoi
susedf
orcul
ti
vat
ion.
- Cel
lcul
tur
esusedar
e–HEP–2,
Det
roi
t–6andot
hercel
ll
ines
- Ani
mal
susedf
orgr
owt
hofr
icket
tsi
aear
emi
ce&Gui
neapi
gs.
ANTI
GENSTRUCTURE:
1)Gr
oup speci
fi
c sol
ubl
e ant
igen pr
esenton sur
face – obt
ained byr
epeat
ed
washi
ng
2)Speci
esspeci
fi
cAnt
igenpr
esentonbodi
esofr
icket
t–i
tisst
rai
nspeci
fi
cinR.
Tsut
sugamushi
.
3)Al
kal
ist
abl
epol
ysacchar
ideAnt
igen–cr
ossr
eact
swi
thPr
oteusAgusedi
nWei
l
Fel
i
xtest
.
TOXI
NS:
1)Endot
oxi
n
2)Heamol
ysi
n
PATHOGENESI
S:
Ri
cket
tsi
aeent
erbybi
teofv
ect
or

Theymul
ti
plyl
ocal
l
y

Ent
eri
ntobl
ood

69
 Local
i
sedi
nVascul
arendot
hel
i
alcel
l
s

Thesecel
l
senl
arge,
degener
ateandcauset
hrombusf
ormat
ion,
causi
ng
occl
usi
onofv
ascul
arl
umen
TYPHUSFEVERGROUP:
Epi
demi
cTy
phus:
I
ncubat
ionper
iodi
s5-
21day
s.Fev
erandchi
l
lsar
ethei
nit
ialf
eat
uresandi
snot
t
h t
h
di
ff
erent
iat
edf
rom ot
her
sti
l
lther
ashappear
son4 or5 day
.Rashi
smacul
opapul
ar,
st
art
sont
runkandspr
eadov
ert
hel
i
mbsbutspar
ingt
hef
ace,pal
msandsol
es.The
namet
yphuscomesf
rom t
hecl
oudyst
ateofconsci
ousnessi
nthedi
sease.Deat
hrat
e
i
s15-
70%.
Endemi
cTy
phus:
Tr
ansmi
tt
edbyt
hebi
teoff
leas.I
ngest
ionoff
oodcont
ami
nat
edwi
thr
atf
leaal
so
t
ransmi
tthedi
sease.I
tismi
l
dert
hanepi
demi
cty
phus.
Recr
udescentTy
phus:
Br
il
landZi
nsser
,ident
if
i hatR.Pr
edt owazekir
emai
nsl
atenti
nthel
ymphat
ics
andl
ymphnodesofi
nfect
edper
sonf
ory
ear
sandmayatt
imesget
sreact
ivat
edt
ofor
m
r
ecr
udescentt
yphus(
Bri
ll
-Zi
nsserDi
sease)
.
SPOTTEDFEVERGROUP:
- Tr
ansov
ari
alt
ransmi
ssi
oni
sseeni
nti
ckswhi
chact
sbot
hasav
ect
orand
r
eser
voi
rhost
.
- Rockmount
ainspot
tedf
everi
sthemostser
ioust
ypeandi
tresembl
esepi
demi
c
t
yphuscl
i
nical
l
y,butt
her
ashwhi
chi
smacul
ari
nit
ial
l
ybecomespet
echi
all
ater
,
appear
sont
hef
lexoraspect
sofwr
istandankl
eandspr
eadsal
lov
ert
hebody
i
ncl
udi
ngpal
ms,
sol
es,
buccal
mucosa.Deat
hrat
eis18%.
Ri
cket
tsi
alPoxi
sthemi
l
destdi
seaseofhumanbei
ngs,sel
fli
mit
ed,non-
fat
al,
v
esi
cul
arexant
hemar
esembl
i
ngchi
ckenpox.I
tisal
socal
l
edv
esi
cul
arorv
arcel
l
ifor
m
r
icket
tsi
osi
s.I
tgi
ves+i
veNei
l
-Mooserr
eact
ion.
Scr
ub Ty
phus:I
twasf
ir
stobser
ved i
n Japan wher
eitwasf
ir
stf
ound t
o be
t
ransmi
tt
edbymi
tes.Thedi
seasewast
her
efor
ecal
l
edt
sut
sugamushi(
Tsut
suga–
danger
ons,
mushi
–mi
te)
.

70
 I
tisseeni
nscr
ubj
ungl
es,sandybeaches,mount
ain,deser
tsandequat
ori
alr
ain
f
orest
s.
Humanbei
ngsget
sinf
ect
iononl
ywhent
heyt
respassi
ntot
hesemi
tei
slandsand
bi
tt
enbyt
hesemi
tel
arv
ae(
Chi
gger
s).
Zoonot
ict
etr
aidessent
ialf
ort
hemi
crof
ocusofi
nfect
i eR.Tsut
onar sugamuchi
,
chi
gger
s,r
atsandt
ransi
ti
onal
for
msofv
eget
ati
on.
I
ncubat
ionper
iod=1–3weeks.
CLI
NICALMANI
FESTATI
ONS:
- Escharatt
hesi
teofmi
tebi
te.
- Fev
er,
headache,
conj
unct
ival
inf
ect
ion.
- Rasht son5thday
hatappear .
- Mor
tal
i
tyr
atei
s0.
5to60%.
Thr
eeant
igeni
cty
pesoft
sut
sugamushi
areKar
p,Gi
ll
iam andKat
o.
TRENCHFEVERORFI
VEDAYFEVER:
- Fi
rstobser
veddur
ingf
ir
stwor
ldwaramongsol
dier
sfi
ght
ingi
ntr
enchesi
n
Eur
ope.
- Thedi
seasewasnotf
atal
,buti
tssl
owcour
seandpr
olongedconv
alescencel
ead
t
oconsi
der
abl
elossofmanpower
.
- Noext
rahumanr
eser
voi
randi
sexcl
usi
vel
yahumandi
sease.
- CausedbyRo.Qui
ntana.
Ro.Qui
ntanadi
ff
ersf
rom Ri
cket
tsi
aei
nfol
lowi
ngaspect
s:
1)I
toccur
sext
racel
l
ular
lyi
nar
thr
opodhost
.
2)I
tgr
owspoor
lyi
nyol
ksaeofchi
ckembr
yos.
3)I
tdoesnotcauseexper
iment
ali
nfect
ioni
nanyl
abani
mal
s.
4)I
tcangr
owonbl
oodagarunderi easedCO2andat37oC.
ncr
5)I
tdoesnotr
eactwi
thWei
lFel
i
xant
igen
‘
Q’f
everor
Quer
yfev
erdi
scov
eredsepar
atel
ybyCoxandBur
netandhencet
he
Ri
cket
tsi snamedasCoxi
aei ell
aBur
net
ti
.

EPI
DEMI
OLOGY:

- I
tisazoonot
icdi
sease.

71
MODEOFI
NFECTI
ON:

Or
gani
sms ent
er t
hrough abr
aded ski
n,l
ungs,mucosa membr
ane and
gast
roi
ntest
inal
tract
.

MORPHOLOGY:

Pl
eomonphi
csmal
lrodsorspher
es,
fil
ter
abl
e,gr
am negat
ive.

PROPERTI
ES:

- I
tisr
elat
ivel
yresi
stantt
ophy
sical
andchemi
cal
agent
s.

- I
tsur
viesat4oCf
v or1y
earandi
nmeatf
oramont
h.

- I
tisr
esi
stantt
opast
eur
izat
ionbyhol
dmet
hod.

- I
tgr
owswel
li
nyol
ksaeofchi
ckembr
yoandi
ncel
lcul
tur
es.

- I
texhi
bitphasev
ari
ati
on.

DI
SEASE:

- Mani
festasi
nter
sti
ti
alpneumoni
a

- Hepat
it
isandendocar
dit
is.

LABDI
AGNOSI
SOFRI
CKETTSI
ALDI
SEASES:

1)I
sol
ati
onofRi
cket
tsi
ae

2)Demonst
rat
iononAbbyser
ology

I
sol
ati
on shoul
d be at
tempt
ed onl
yinl
abs wi
th saf
ety pr
ovi
sions,si
nce
r
icket
tesi
aear
ehi
ghl
yinf
ect
ious.

I
SOLATI
ONOFRI
CKETTSI
AE:

Speci
men:Bl
ood

Met
hod:I
nocul
ati
onofspeci
meni
ntr
aper
it
oneal
l
yinmal
egui
neapi
g.Ani
mal
s

72
obser
vedf
or3-
4weeksandt
hei
rtemper
atur
erecor
deddai
l
y.

Spot
tedf
evergr
oup:pr
oducef
ever
,scr
otal
necr
osi
sanddeat
hofgui
neapi
g

R.t
yphi
,R.Conor
i,R.Akar
i–f
everandt
uni
car
eact
ion(
Nei
l
-Mooserr
eact
ion)

R.Pr
owazekiand Cox.Bur
net
ti
– pr
oduce onl
yfev
erwi
thoutanyt
est
icul
ar
i
nfl
ammat
ion.

Smear
sfr
om per
it
oneum,t
uni
caandspl
eenofi
nfect
edani
mal
smaybest
ained
byGi
emsaandGi
menezmet
hodst
odemonst
rat
ether
icket
tsi
ae.

Sennet
suf
ev oducedbyEhr
erpr li
chi
asennet
su,i
ntr
aleucocy
tepar
asi
tet
hati
nfect
s
human bei
ngsand ani
mal
s. Di
seasei
schar
act
eri
sed byf
ever
,ly
mphadenopat
hy,
at
ypi
call
ymphocy
tesi
nper
ipher
albl
ood.Endemi
cinJapanandSout
hEastAsi
a.Dogs
mayactasr
eser
voi
rhost
s.

73