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34. Enumerate common causes of food poisoning. (3 Marks)
Answer:
o Food poisoning is an illness caused by the consumption of food or beverages
contaminated with microorganisms or toxins.
Clinical Likely
Timing of
Diagnostic Common
Clinical
Features Microorganism Approach Food Sources
Features
Vomiting, Staphylococcus 1-6 h post Clinical presentation Dairy, meat,
diarrhea, aureuS ingestion salads, mayo
cramps
Bacillus cereus 1-6 h post Clinical presentation Rice dishes,
ingestion reheated foods

|Abdominal Clostridium 8-16 h

post-Clinical presentation Meat, poultry,
cramps, perfringens ingestion gravies
diarrhea
Watery Vibrio cholera 16-72 h Clinical presentation,Contaminated
diarrhea post-ingestion stool culture, water, seafood
serology
|Bloody Enterotoxigenic 6-72 h post-Clinical presentation,| Contaminated
diarrhea E. coli; ingestion stool culture, PCR water, food
EHEC
Inflammatory Enterohemorrhagic6-72 h
post-Clinical presentation, Undercooked
diarrhea E. coli (EHEC) ingestion stool culture, beef, veggies
serology
Dysentery Shigella species 1-7 days Clinical presentation,|Contaminated
post-ingestion stool culture, PCR water, raw
produce
Inflammatory Campylobacter Clinical presentation,Undercooked
2-5 days
diarrhea |jejuni post-ingestion stool culture, PCR poultry, dairy

Flaccid Clostridium 12-72h Clinical presentation, lmproperly

paralysis, botulinum post-ingestion electromyography, canned foods
diplopia, toxin assay
dysphagia
Fever, mnyalgia Listeria Variable Clinical presentation, Soft cheeses,
(pregnant) monocytogenes blood culture, PCR deli meats

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Bacillus cereus Diarrheal type Emetic type

Incubation period 8-16 hours 1-5 hours
Toxin Secreted in intestine Preformed toxin present
in food
|Heat sensitivity Heat labile Heat stable
Food items contaminated Meat, vegetables, dried Rice (Chinese fried rice)
beans, cereals
Clinical feature Diarrhea, fever, Vomiting, abdominal
abdominal cramps cramps
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 394

MedE

RMedE
GIT Infections

MedEd FARRE: Microbiology

35. Write a short a note on giardiasis (5 Marks)

Answer.
MORPHOLOGY
o Cyst Stage:
.
Cysts are the infective form and are excreted in the feces
Oval or ellipsoidal in shape.
* They have a thick, durable, and translucent wall that helps protect the parasite
in harsh environmental conditions
* Inside the cyst, there are usually two nuclei, four flagella (hair-like structures
used for movement)
o Trophozoite Stage:
* Trophozoites are the active, motile, and feeding stage of Giardia that exist in
the small intestine.
* They are pear-shaped or teardrop-shaped.
* They have two adhesive dises (ventral and dorsal) that allow them to attach to
the intestinal lining and resist peristalsis (intestinal muscle contractions).
Trophozoites have two nuclei and four pairs of flagella, making a total of eight
flagella.

Ingestion of Giardia Cysts

Transmisslon

Excystation in
duodenum
Excretion in Feces

Trophozoite released and

divides by binary fission
Cyst forms

Encystation

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Sucking disk
Nucleus

Axoneme

Flagella
Parabasal
body

Cyst wall
Axoneme
Nucleus

CLINICAL FEATURES
o Asymptomatic: These people are carriers of the pathogen who release these cyst in
feces but themselves do no manifest any symptoms or signs of the disease
o Acute giardiasis: Symptoms include diarrhea, bloating, abdominal pain etc.
o Steatorrhea: This occurs due to fat malabsorption. There is malodorous pale sticky
stools are released in feces.
o Chronic giardiasis: This is due to persistence of infection and include foul smelting
diarrhoea flats along with extra intestinal manifestations like urticaria anterior
uveitis and generalised weight los.
LABORATORY DIAGNOSIS
Stool Examination:
o A fresh stool sample is collected from the patient.
o Wet mount: The sample is microscopically examined for the presence of Giardia
cysts or
trophozoites.st
o Concentration techniques, such as sedimentation or flotation, may be used to
increase the chances of detecting the parasites

89 RMedEd
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STOOL ANTIGEN TEST KNOWN AS COPROANTIGEN

o Enzyme immunoassays (EIAs) or immunochromatographic assays are used in this
method.
o They detect specific Giardia antigens in the stool.
MOLECULAR TESTS
o Polymerase chain reaction (PCR) tests are highly sensitive and specific for Giardia
diagnosis.
SEROLOGICAL TESTS
o
Using ELISA and IFA
CULTURE
o ln Diamond nmedium. These are done for research generally.
o Duodenal Aspirate or Biopsy: Done using Entero-string test
O In severe or chronic cases of giardiasis, or when other diagnostic methods are
inconclusive, an endoscopy procedure may be performed.
O A sample is collected directly frowm the duodenum, which is the part of the small
intestine most commonly affected by Giardia.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, No. 433

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36. Write in detail about the diarrhoea causing E.coli? (10 Marks)
Answer
VIRULENCE FACTORS
O Fall into two categories: surface antigens and toxins.
o
Surface antigens encompass somatic (0), flagellar (H), capsular (K), and fimbrial
antigens.
* Somatie or o antigen: Found on lipopolysaccharides, triggering antibody
production.
Flagellar or H antigen: Responsible for bacterial movement and virulence.
* Capsular or K antigen: Hinders phagocytosis, expressed by specific pathogenic
E. coli.

* Fimbrial antigen (pilus): Involved in adhesion, attachment, and colonization.

O Toxins:

* Enterotoxins (heat-labile or heat-stable).

* CNFL is cytotoxic to bladder and kidney cells, contributing to urinary tract
infections.
CLINICAL FEATURES

o causes diverse manifestations:

E. coli

* Urinary tract infection (UT) primarily by uropathogenic E. coli (UPEC).

* Diarrhea induced by six pathotypes of diarrheagenic E. coli (EPEC, ETEC, EIEC,
EHEC, EAEC, DAEC).
* Abdominal infections (primary bacterial peritonitis, secondary bacterial
peritonitis, hepatic abscesses).
* Pneumonia (especially in hospitalized patients).
* Meningitis (neonata).
Wound and soft tissue infections (e.g., cellulitis),.
* Bacterial prostatitis.
> Osteomyelitis.
LABORATORY DIAGNOSIS
o
Direct Smear (Gram Staining): Gram-negative straight rods.
o Culture: Aerobic and facultative anaerobe, using media like blood agar and
MacConkey agar.
o ldentification: MALDI-TOF or VITEK, Catalase test (positive), Oxidase test (negative),
ICUT tests (lndole test, Citrate test, Urease test, TSI test).

RMedEd
GIT Infections

MedEd FARRE: Microbiology

DIARRHEAGENICE.COLI
o Diarrheagenic E. coli strains are distinct from the commensal E. coli that normally
inhabit the intestine. There are six pathotypes of diarrheagenic E. coli:

Pathotype Characteristics Major Clinical

Presentation
O Common in infantile diarrhea o Watery diarrhea,
outbreaks. especially in infants
O Adhesion to intestinal mucosa, and children.
Enteropathogenic
E. coli (EPEC) causing A/E lesions (attaching and
effacing lesions)
o Disrupts the brush border
epitheliuwm.
O Major cause of traveler's diarrhea. O Acute watery
O Produces heat-labile and heat diarrhea in both
Enterotoxigenic
E. coli (ETEC) stable toxins. infants and adults.
O Adheres to intestinal mucosa via
colonization factor antigen (CFA).
o
Biochenmically, genetically, and O Dysentery (bloody
Enteroinvasive pathogenically related to Shigella. diarrhea with
E. coli (EIEC)
O Invasive, not toxigenic. mucus and
O lnvades epithelial cells through blood), resembling
virulence marker antigen (VMA). shigellosis.
o
Serotype 0157:H7 is common, o Hemorrhagic
o
but others can cause infections. colitis (gross
Typically transmitted through bloody diarrhea),
Enterohemorrhagic cOntaminated food. abdominal pain,
E. coli (EHEC)
o Produces verocytotoxin or Shiga fecal leukocytosis.
toxin (Stx1 and Stx2). o Hemolytic Uremic
Syndrome (HUS)
O Adheres to HEp-2 cells in a O Persistent and
stacked -brick fashion. acute diarrhea,
Enteroaggregative o Produces EAST 1 toxin
E. coli (EAEC) traveler's diarrhea,
(enteroaggregative heat-stable and persistent
enterotoxin 1). diarrhea in infants.
o Adheres to HEp-2 cells in diffuseo Diarrheal disease,
a
Difusely-Adherent pattern, mainly in children.
E. coli (DAEC) O Expresses diffuse adherence
fimbriae.
Reference: Essentials of Medical 'Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, No. 401

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37. Write a short note on H.pylori infection. (5 Marks)

Answer.
O Helicobacter pylori is a curved, gram-negative rod-shaped bacterium that
primarily inhabits the stomach. It is associated with conditions like peptic ulcer
disease and gastric carcinoma.
PATHOGENESIS
Several factors favor H. pylori colonization:
o Motility: H. pylori is highly mobile due to its 4 to 8 unipolar flagella, allowing it to
navigate the mucus layer covering the gastric mucosa effectively.
o
Acid Resistance: This resistance might result from its production of urease enzyme,
which hydrolyzes urea to produce ammonia, buffering the gastric acid. Amidase
and arginase enzymes may also cOntribute to ammonia production.
O Adhesins: can bind to mucosal epithelium using adhesion molecules like blood group
antigen -binding adhesin and adherence-associated lipoprotein.
o Resistance to Oxidative Stress: H. pylori has various detoxifying enzymes that
protect it from oxygen-derived free radicals produced during its metabolism and
by the host's inflammatory response.
H. pylori induces pathological changes through toxins:
o Vacuolating Cytotoxin (VacA): Thís toxin is secreted by H. pylori and causes the
formation of vacuoles within the cytoplasm of epithelial cells.
o Cytotoxin-Associated Gene A (CagA): CagA helps the bacterium alter the host cell's
metabolism.
o Molecular Mimicry
O lmmune Tolerance: H. pylori may downregulate T cells, promoting immune
tolerance.
o Autoantibodies: Autoantibodies generated due to molecular mimicry can cross
react with mucosal epitopes, contributing to chronc active gastritis.
CLINICAL MANIEESTATIONS
o Acute Gastritis: Typically affects the antrum of the stomach
o Pangastritis: Increases the risk of gastric adenocarcinoma.
o Duodenal ulcers may develop due to H. pylori-induced inflammation, which
inhibits somatostatin-producing D cells, leading to increased gastrin release and
subsequent acid secretion.
o Common Symptoms: Epigastric pain with a burning sensation is a common
presentation, occurring after meals in duodenal ulcers and on an empty stomach
in gastric ulcers.

RMedEd
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MedEd FARRE: Microbiology

CHRONIC CONDITIONS ASSOCIATED wITH H. PYLORI INFECTION

o Chronic Atrophic Gastritis
O Autoimmune Gastritis
O Pernicious Anemia
o Adenocarcinoma of the Stomach
O Gastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphomas

LABORATORY DIAGNOSIS
Invasive Tests:
o Endoscopy-Guided Biopsies: During endoscopy, multiple biopsies are taken fron
the gastric mucosa, including the antrum and corpus.
o Histopathology with Warthin Starry Staining: Biopsy samples can be stained and
examined for the presence of H. pylori.
MICROBIOLOGICAL METHODS
o Gram Staining: H. pylori appears as curved gram-negative bacilli with a distinctive
seagull-shaped morphology.
O Culture: Culture is highly specific but not very sensitive. Sirrow's media and
chocolate agar are commonly used culture media.
o
Biopsy Urease Test (Rapid Urease Test): This test detects urease activity in gastric
biopsies using a urea -containing broth with a pH indicator. It is rapid, sensitive,
and cost-effective.
NONINVASIVE TESTS
Urea Breath Test: ln this noninvasive test in which we detect labeled Carbon in
o

breath of the patient

o Fecal antigen detection: highly sensitive and specific test
o Antibody detection: Done using ELISA
TREATMENT
o Triple therapy is commonly used which consists of one PPI + metronidazole +

tetracycline.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, No. 42o

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38. Write a short note on Clostridium difficile. (s Marks)

Answer:

C. difficile
o Obligate anaerobie, gram-positive, spore -forming bacillus
Introduction o Causes pseudomembranous colitis
o Linked toprolonged antimicrobial drug se(Ceftriaxone,
Clindamycin, Ciprofloxacin etc.)
O
Healthcare-Associated Infection
Risk Factors:
o Prolonged Hospital Stay
Pathogenesis o Prolonged Antimicrobial Use
o Toxin Production (Toxins A and B disrupt cellular actin
cytoskeleton)
o
Infants are less susceptible due to lacking toxin receptors
o Diarrhea (most common)
O Fever
O Abdominal Pain
Clinical
O Leukocytosis
Manifestations
O Blood in Stool
o Pseudomembrane Forwation (whitish-yellow plaques on
colonic mucosa)
o Stool Culture (under anaerobic conditions with selective
media)
O Toxin Demonstration (via assays, antigen detection, toxin
A/B presence)
o
Glutamate Dehydrogenase (GDH) detection (not specific
Laboratory for toxins)
Diagnosis
o Molecular Methods (PCR, real-time PCR, gene Xpert for
specific genes)
o Colonoscopy (if pseudomembranes observed)
o Histopathology (using hematoxylin and eosin stain on
pseudomembranes)
Treatment O DOC: Oral vancomycin (Fidaxomicin/Metronidazole)

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, No. 422

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o Symptoms: abrpt onset, including vomiting, watery diarrhea, fever, abdominal

pain, electrolyte imbalance, and possible shock.
L(C) LABORATORY DIAGNOSIS:

Direct Detection of the Virus:

O ldeal specimen: early-collected feces.
O
Methods: lmmunoelectron Microscopy (lEM), isolation, detection of viral antigen
(ELISA, Iatex agglutination), RT-PCR.
Serologic Tests:
o ELISA for changes in antibody titers.
Treatment of Viral Gastroenteritis:
o Supportive care focuses on fluid and electrolyte correction through oral or
parenteral fluid replacement.
VACCINES
Rotavac:
o
Contains live attenuated Rotavirus, and provides cross-protection against various
types.
o Schedule: Administered orally in three doses at 6, 10, and 14 weeks of age,
alongside routine vaccines.
o Comwmon side effects: crying, irritability, fever, and diarrhea.
Rotarix:
o attenuated vaccine, requires reconstitution before
Live use.
o Given in 2 doses at 6 and 10 weeks of age.
Other Agents:

Virus Characteristics
o Transmitted by fecal-oral route
Rotavirus O Affects the snall intestine
o Causes secretory diarrhea
o
Part of Caliciviridae family
o lcosahedral shape
Norovirus
Approximately 27-40 nm in size
o
oCauses epidemic gastroenteritis
o Part of Caliciviridae family
Sapovirus o lcosahedral shape
o Approximately 27-40 nm in size

MedEd
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MedEd FARRE: Microbiology

o Types 40 and 41 cause diarrhea

Adenovius o Common in young children
O Responsible
for diarrhea
o STAR-ike morphology
Astroviruses o Approximately 28-30 nm in size
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat,
3rd
Edition, No. 424

ledEd

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o In severe cases, pulmonary manifestations may escalate toeosinophilic pneumonia,

known as Loeffler's syndrome. This condition may manifest with:
* Dyspnea
Transient patchy infiltrates visible on chest X-rays
* Peripheral eosinophilia
INTESTINAL PHASE
o The intestinal phase of Ascaris infection leads to several clinical manifestations,
including:
* Malnutrition and Growth Retardation: Particularly in children under five
years old, chronic malnutrition and stunted growth can result from
ntrient
competition with the parasites.
o Intestinal Complications: A significant aggregation of entangled worms within the
intestines can precipitate complications such as:
Obstruction
* Rare but severe events like perforation, intussusception, or volvulus
o Extraintestinal Complications: Larger worms may enter and obstruct the biliary
tree, giving vise to:
Biliary colic
o Cholecystitis
* Pancreatitis
Allergic Manifestations: The presence of adult worms can provoke allergic reactions,
leading to symptoms like:
O Fever
o Urticaria
O Angioneurotic edema
o Conjunctivitis
Laboratory Diagnosis:
o Stool Examination: Both fertilized and unfertilized Ascaris eggs can be identified
in stool samples using saline and iodine wet mounts.
O Detection of Adult Worms: Adult worms may occasionally be visible in stool or
sputum. Barium meal X-rays can reveal adult worms in the intestine, with two
aligned worms appearing as "trolley car lines" on X-rays.
o Detection of Larvae: During the early pulmonary migratory phase, larvae can be
found in sputum or gastric aspirates before eggs appear in stool sawmples.

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o Antibodies Detection: Although not commonly performed, serological tests, such

as ELISA, can be used to detect antibodies against Ascaris.
o Molecular Methods: PCR targeting the cytochrome oxidase -1 gene of Ascaris eggs
in stool samples can provide a sensitive diagnostic tool.
o Other Tests: Eosinophilia and the presence of Charcot Leyden crystals in sputum
can provide additional diagnostic clues.
TREATMENT
o Albendazole
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, No. 461

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41. Write in detail about Entamoeba histolytica including intestinal amoebiasis and
amoebic liver abscess. (10 Marks)
Answer:
MORPHOLOGY
E.histolytica exists in three stages:
o Trophozoite: The invasive, feeding, and replicating form found in the feces of
individuals with active disease, contain a single nucleus, and have finger-like
projections called pseudopodia for locomotion.
o Precyst: An intermediate stage between trophozoite and cyst.
o Cyst: The diagnostic form of the parasite found in the feces of carriers and
individuals with active disease. Cysts can contain 1-4 nuclei. Mature cysts are
quadrinucleated and represent the infective form of the parasite.
LIEE CYCLE OF ENTAMOEBA HISTOLYTICA
o
It completes its life cycle within a single host, which is typically a human.
o Infective Form: The mature quadrinucleate cyst
o Mode of Transwmission:
* Fecal-Oral Route (Most Common): This is the primary mode of transmission,
Sexual Contact: Transmission can also occur through anogenital or orogenital
cOntact.
Rare Vector Transmission: ln very rare cases, vectors such as flies and cockroaches
DEVELOPMENTIN THE HUMAN
o Small lntestine: Cysts bypass the gastric juice and reach the small intestine, where
they undergo excystation. Trypsin in the small intestine lyses the cyst wall, releasing
four small trophozoites.
o Large intestine: Trophozoites are carried to the ileocecal region of the large intestine.
Here, they multiply by binary fission and then colonize the intestinal mucosa. The
subsequent course depends on the host's susceptibility:
* Asymptomatic Cyst Passers
o Amoebic Dysentery
> (nvasive Amoebiasis
• Encystation: When intestinal lesions start to heal, and the patient improves,
trophozotes transform into precysts and then into cysts, which are subsequently
liberated in feces.
MIRULENCE FACTORS
o Amoebic Lectin Antigen: surface protein (Gal/NAG lectin) is a principal virulence
factor. It aids in adhesion by binding to glycoprotein receptors on the large intestinal
epithelium and vascular endothelium.

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o Other Virulence Factors: These include
* Amoebapore, which forms pores on the target cell membrane, causing ion
leakage.
o Hydrolytic enzymes
PATHOGENESIS
o Colonization: Trophozoites initially colonize the intestinal mucosa, and this process
facilitated by the presence of bacterial flora that lower the OKygen tension.
O Adhesion: using Gal/GalNAc lectin molecules.
o Flask-shaped Ulcers: Trophozoites produce characteristic flask-shaped ulcerative
lesions in the large intestine, with a broad base and a narrow neck.
o Invasion: Following ulcer formation, amoebae invade the large intestinal wall and
can migrate to extraintestinal sites.
Clinical Manifestations of Intestinal Amoebiasis:
o Incubation Period: Typically varies from one to four weeks.
O Asymptomatic Cyst Passers: About 90%
O
Symptomatic Cases:
9 Amocbic Dysentery: Symptoms include bloody diarrhea (up to 1o times per
day), mucus and pus in stool, colicky abdominal pain, fever, prostration, and
weight loss.
* Amoebic Appendicitis: Presents with acute right lower abdominal pain.
* Fulminant Colitis: Presents with intense colicky pain, rectal tenesmus, frequent
bowel movements (more than 20 times per day), fever, nausea, anorexia, and
hypotension.
Complications of Intestinal Amoebiasis include:
o Intestinal Perforation and Amoebic Peritonitis
o Toxic Megacolon and Intussusception
O Amoebiasis Cutis or Cutaneous Amoebiasis: Presents as perianal skin ulcers,
o Ameboma (Amoebic Granuloma): A diffuse pseudotumor-like mass of granulomatous
tissue found in the rectosigmoid region.
o Chronic Amoebiasis: Characterized by thickening, fibrosis, stricture formation, and
scarring.
cLINICAL MANIEESTATIONS OF AMOEBIC LIVER ABSCESS

o Tender Hepatomegaly: Enlargement of the liver with tenderness is a common and

cOonsistent feature.
o Fever, weight Loss, profuse sweating
o Anchovy sauce pus

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Complications of Amoebic Liver Abscess include:

o Rupture: The abscess may rupture in various directions within the liver, leading to
the discharge of its contents into neighboring organs (lungs for example)
o
Subphrenie Abscess: Rupture below the diaphragm can result in a subphrenic
abscess and generalized peritonitis.
o Left-Sided Liver Abscess:
Stomach Rupture: Left-sided abscesses may rupture into the stomach.
* Pleural Rupture: Rupture into the left pleura is another possibility.
* Pericardial Cavity: Amoebic pericarditis can occur if the abscess ruptures into
the pericardial cavity.
LABORATORY DIAGNOSIS
O Microscopy: Examination of liver pus or stool under a microscope can detect
trophozoites, the active form of the amoeba.
o Stool culture
o Polyxenic culture in National lnstitute of Health media (NIH).
* Axenic culture using Diamonds media.
o Sigmoidoscopy done to take biopsies and stained with PAS stain and H&E stain
to detect trophozoite.
o
Antigen Detection: Using ELISA The lectin antigen can be demonstrated in
stool,serum, liver pus, and saliva.
o
Antibody Detection: Serum antibody detection is more useful for extraintestinal
amoebiasis than intestinal amoebiasis. ELISA tests are available
o Molecular Diagnosis: PCR and real-time PCR
o lmaging Methods: Ultrasonography (USG) of the tiver can reveal the location of the
abscess and its extension. CT Scans and MRI scans are alternative options.

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, No. 427

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42. A 45 yr old male comes to the opd with complaints of profuse watery diarrhea
and vomiting that began suddenly 12 hours ago. He has had more than 10
episodes of diarrhea and has vomited several times. The diarrhea is deseribed as
"rice water" in appearance. He says that he went to eat some street food days
back.
2
(A) What is the probable diagnosis?
(B) Write the Pathogenesis, clinical feature and laboratory diagnosis.
(C) Write in brief about Halophilic vibrio infection. (10 Marks)
Answer:
(A)
The probable diagnosis according to the history and appearance of stool is watery
diarrhoea due to vibrio cholerae.
Vibrio are mainly classified into 2 based on the salt requirement for its growth
O Non-halophilie- They can grow without salt but their growth is enhanced if 1%
salt ispresent in the medium. Eg- v.cholerae and v.mimicus
o Halophlic- These require a specific concentration of salt in the medium for their
optimal growth.eg-v.vulnificus,v. parahaemolyticus etc.
L(B) PATHOGENESIS

o Mode of Transmission: through the ingestion of contaminated water or food. The

infective dose is high,
O
Reduced Gastric Acidity: Conditions that reduce gastric acidity, such as
hypochlorhydria or the use of antacids, can promote the transmission of Vibrio
cholerae.
o Penetration of Mucus Layer Vibrio cholerae must penetrate the protective mucus
layer in the small intestine to establish infection. It achieves this through factors
like its active motility, the secretion of mucinase and proteolytic enzymes, and the
production of cholera lectin, which cleaves mucus and fibronectin.
o
Adhesion and Colonization: The bacterium adheres to the intestinal epithelium,
facilitated by toxin-coregulated pilus (TCP).
o Cholera Toxin: Once established in the small intestine, Vibrio cholerae produces
cholera toxin, a potent enterotoxin.

105 MedEd
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MedanindOdra Toaâr Cholera bin b composed of o

petide tagrent, A and 8

Fagnet A ten AOPboetes

Gproteins, noasng adenfate
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receçtors on te rd lesdng b tha

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he absort Osum apot stom ns cets

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soduntbide n Nirtestnnen

Wter movesto he tboel Lnen pssey bnaintain oarolaly

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dartea

CLINICAL FEATURES
o Cholera caused by V. cholerae 01 or 0139 can manifest in various ways,
o Asymptomatic Infection: Many infected individuals do not show any symptoms
and remain asymptomatic.
o Mild Diarrhea or Cholera: Some individuals may experience mild diarrhea.
o Cholera Gravis (5% of Cases): This is the most severe form and is characterized by
explosive, fife-threatening diarrhea.
Common Clinical Manifestations:
o Watery
Diarrhea: Cholera typically starts suddenly with painless, profuse, watery
diarrhea that can quickly become voluminous.
o Rice Water Stool: The stool in cholera is distinctive, appearing as non-bilious,
slightly cloudy, and watery with mucus flakes. It has a fishy, inoffensive odor and
often resembles the water used to wash rice. Unlike some other diarrheal diseases,
cholera does not result in bloody or pus-filled stools.
o Vomiting
o Muscle Cramps: Electrolyte imbalances due to fluid loss can lead to muscle cramps.

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LABORATORY DIAGNOSIS
Specimens collection
o Freshly collected watery stool is the preferred specimen for acute cases of cholera.
o Transport Media:
$ Specimens should be transported to the laboratory as soon as possible. If there is
an expected delay, specimens can be inoculated into transport media to maintain
the viability of the bacteria. These media include Venkatraman-Ramakrishnan
(VR) medium, alkaline salt transport medium, Cary-Blair medium, or autoclaved
seawater.
Direct Microscopy:
o Gram staining of mucus flakes in feces can reveal short, curved, comma-shaped,
gram-negative rods, arranged in parallel rows. This appearance is often described
as a "fish in stream" pattern.
O
Motility testing using the hanging drop method can show active, darting motility
of the bacteria.
Culture:
o Enrichment broth is incubated for several hours, and then a subculture is made
onto another selective medium. This process helps isolate and identify V. cholerae.
Commonly used are
o Alkaline peptone water
3 Monsur's taurocholate tellurite peptone water
o Selective media
TCBS agar- Thiosulphate citrate bile sat agar produces yellow colonies
* Alkaline bile salt agar- produces oil drip colonies
o MacConkey agar
Identification:
o Catalase and oxidase: Positive.
> ICUT test: This test assesses reactions to various biochemicals, including:
Indole test: Positive.
3 Citrate test: Variable.
Ureasetest: Negative.
TSI(triple sugar iron agar test): V. cholerae is a sucrose fermenter, so it typically
shows an acid/acid reaction, gas absent, and H2s absent on this test.
o Hemodigestion: On blood agar, V. cholerae causes nonspecific ysis of blood cells,
seen as a greenish clearing.

107 KMedE
< GIT Infections

MedEd FARRE: Microbiology

o String test: On miking the colony with o.5% deoxycholate, the colony becomes
mucoid and forms a string when lifted with a loop.
ANTIGEN DETECTION
o Dipstick tests are available for cholera.
MOLECULAR METHODS
o PCR can be used to detect cholera-specific genes in stool samples.

Halophilic vibrio can withstand salt concentration even more than 6% while non
halophilic can only withstand up to 6..
Vibrio parahaemolyticus Infections:
o These infections are commonly associated with consuming raw or uncooked seafood,
particularly oysters.
o Clinical manifestations include food -borne gastroenteritis, which typically presents
as watery diarrhea or, rarely, as dysentery with abdominal cramps.
o Laboratory diagnosis
O Morphology -Bipolar staining in fresh specimens
o TCBS agar-greein colonies on
o Kanagawa phenomenon: Beta hemolysis on wagatsuma agar.
o Swarming on blood agar.
Vibrio vulnificus Infections:
o V. vulnificus can cause two distinct syndromes:
* Primary sepsis, which is severe and occurs in individuals with underlying liver
disease or other conditions, and primary wound infection, which affects healthy
individuals.
* Primary wound infection typically presents with painful erythematous swelling,
cellulitis, and vesicular, bullous, or necrotic lesions.
o Laboratory diagnosis involves culturing the bacteria from blood or cutaneous
lesions.
*V. vulnificus ferments lactose, which helps differentiate it from other Vibrio
species.

Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, No. 411

I08)
Hepatobiliary Infections

Hepatobiliary
43. Write the difference between Hepatitis A, C and E. (s Marks)
Answer:

Hepatitis A Virus Hepatitis C Virus Hepatitis E Virus

Aspect (HAV) (HC) (HE)
Fecal-oral route, Bloodborne, often Fecal-oral route,
cOntaminated food through sharing contaminated food
Transmission or water needles or unsafe or water
medical procedures
Typically not chronic,Often leads to |Usually not chronic,
Chronic
Infection usually self-limiting chronic infection. self-limiting

Yes No In some regions,

Vaccination
vaccines are available
Available

Generally milder, Can lead to Severity varies, often

Severity of rarely fatal chronic liver mild but can be
disease, cirrhosis, severe in some cases
Illness
and hepatocellular
carcinoma
Incubation 2-6 weeks 2-12 weeks 2-9 weeks
Period
Serology tests (lgM Blood tests Serology tests (lgM
Diagnosis and lgG) and liver for HCV RNA, and lgG) and liver
function tests antibodies function tests
Supportive care, Antiviral Supportive care,
no specific antiviral medications no specific antiviral
Treatment treatmnent (Direct-acting treatment
antivirals)
Anyone can be People who sháre Pregnant women
infected needles, healthcare and those with
Risk Groups
workers at risk comprowmised
immune system.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, No. 476
< Hepatobiliary Infections
MedEd FARRE: Microbiology

44. Write a short note on Hydatid disease. (5 Marks)

Answer:
Causative Agent:
o Cystic Echinococcosis (Hydatid Disease) caused by Echinococcus granulosus.
Other Echinococcus Diseases:
O Alveolar Echinococcosis (caused by E. multilocularis).
o Polycystic Hydatid Disease.
o Unicystic Hydatid Disease.
Morphology:
o Adult worm resides in the intestine of definitive hosts (e.g., dogs).
o Larval form (hydatid cyst) causes cystic lesions in various organs.
Life Cycle:
O
Involves definitive hosts (dogs) and intermediate hosts (usually herbivores, sometimes
humans).
SHEEP
Acguires irtecton by

MAN igesson c bod cortaminted

(ACODENTA HOST) wh dog's fleos contaning

Egs are
rele HeLacarhertryo
asednsbos hatttes ot
penctates intestre

Ferltion
NTERVEDATE
HOST
Crdaton
AAtmin
alirtesune
DOG
(DEFNITIVE HOST)
Deoirt hcss

ingessed scolex
vagnatesin
testns
Dogs acqure indectan ty
by corsumçion o viscera cf
indecded sheep

Transmission:
o Humans are infected by ingesting food contaminated with dog feces containing
E. granulosus eggs.
Pathogenesis and Clinical Features:
o Fluid-filled bladder-like cyst.
o
Cyst wall consists of pericyst, ectocyst, and endocyst.
o Brood capsules with protoscolices develop inside the cyst.

110
MepatoDIIary Inrecuons

o Hydatid fluid within the cyst is antigenic and toxic.

o Symptoms vary from asymptomatic to abdominal mass, liver enlargement, biliary
or bronchial obstruction, secondary infections, and anaphylactic reactions.
o
Can affect various organs, with the liver and lungs being common sites.
Laboratory Diagnosis (WHO Classification):
o CE1: Active cyst with visible wall and internal echoes (Snowflake sign).
o CE2: Active cyst with visible wall and internal septation (honeycomb appearance).
o CE3: Transitional with detached laminar membranes or partially collapsed (Water
lily sigr).
o CE4: lnactive with non-homogeneous mass.
o CES: Inactive cyst with a thick calcified wall.
Hydatid Fluid Microscopy:
o Examination for hydatid sand.
Histological Examination:
o Stains like Giemsa, H & E, and PAS are used on surgically removed cysts to
demonstrate cyst wall layers and brood capsules.
Antibody Detection:
o ELISA using E. granulosus cyst fiuid antigen or recombinant B2t antigen.
o DIGFA detects serum antibodies against native antigens.
o immunoblot (Western blot) is highly specific for confirmation.
o AntigenB is used for seroepidewmiological studies.
Imaging Methods:
o X-rays detect hepatomegaly and calcified cysts (liver and lungs).
o
Ultrasound (Usa) is preferred for its accuracy.
o CT scans provide detaited information, especially for calcified esions.
o MRI can be used.
Molecular Methods:
o PCR targeting mitochondrial DNA.
o PCR-RFLP (PCR-Restriction Fragment Length Potymorphism).
Skin Test (Casoni Test):
* Immediate hypersensitivity reaction (wheal and flare) after injecting hydatid
fluid antigens.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, No. 443

RMedEJ
<
Hepatobiliary Infections

MedEd FARRE: Microbiology

45. You are an intern working in the department of medicine. While taking the
sample ofa patient you accidentally prick yourself with the sawme needle. You saw
the charts and found that the patient was HBV positive.
(A) What is morphological types of HBV
(B) Write the viral antigens and transmission of HBV?
(C) What is the laboratory diagnosis?
(D) What are the preventive measures for HBV infection? (10 Marks)
Answer:
o HBV is the most common cause of viral hepatitis. It is the only DNA Virus among
other viruses that cause hepatitis.
o It belongs to the family Hepadnaviridae.
HEPATTIS B (HBV)
(A) Morphological forms of HBV
o Electron microscopy reveals three forms of HBV:
Spherical Forms: Small particles, composed exclusively of HBSAg.
* Tubular or Filamentous Forms: Composed exclusively of HBsAg, longer.
Dane Particles: larger (42 nm), comprising outer surface envelope (HBSAg) and
inner nucleocapsid with core antigen (HBcAg) and pre-core antigen (HBeAg),
partially double-stranded DNA.

HBeAg

DNA POymerse Toar torm

Soherlcal lorn

(B) Viral Antigens

o Hepatitis BSurface Antigen (HBsAg): Complex antigen with common and type
specific epitopes, resulting in subtypes adw, ayw, adr, and ayr.
<
Hepatobiliary Infections

o Hepatitis B Core Antigen (HBCAg): lntracellular core protein not secreted into the
bloodstream.
o Hepatitis Be Antigen (HBeAg): Soluble antigen, indicator of active viral replication.
Viral Genome:
OS Gene: Codes for the surface antigen (HBSAg).
oC Gene: Comprises pre-c region (precursor of HBeAg) and C region (HBCAg).
oX Gene: Codes for HBXAg, which activates transcription of cellular and viral genes,
linked to hepatocellular carcinoma.
oP Gene: Codes for polywmerase (P) protein with DNA polymerase, RNase H, and
reverse transcriptase activities.
Transmission:
o Parenteral Route: Cowmmon transmission through blood, needlestick injuries, and
percutaneous exposures.
o Medical Procedures: lnoculation during medical procedures without proper infection
cOntrol.
o Sexual Transmission: Significant in developed countries, especially among homosexual
males.
o Vertical Transmission: From infected mothers to babies during pregnancy,
childbirth, or breastfeeding.
O Direct Skin Contact: Through contact with infected skin/mucous membranes.
o High-Risk Groups: Healthcare workers, paramedical staff, sex workers, recipients
of blood transfusions or organ transplants, drug addicts.
(C) Clinical Features
o
Incubation Period: 30 to 180 days.
o Subclinical Infection: Some show no significant symptoms.
O Acute Hepatitis: Manifests with symptoms:
Pre-lcteric Phase: Fatigue, abdominal discomfort, gastrointestinal symptoms.
> lcteric Phase (Jaundice): Yellowing of skin and eyes, indicating liver dysfunction.
o Hepatic Complications: Cirrhosis, Hepatocellular carcinoma (HCC), fulminant
hepatitis.
o Extrahepatic Complication: Serum-sickness syndrome.
(D) Laboratory Diagnosis
o Viral Markers:
* HBSAg: Appears within 1 to 12 weeks, indicates infectivity.
* HBeAg and HBV DNA: Markers of active viral replication.

113) KMedEd
< Hepatobiliary Infections

MedEd FARRE: Microbiology

3 Anti-HBe Antibody: acute hepatitis, (gã persists long-term.

lgM indicates
* Anti-HBS Antibody: lndicates immunity.

partdes

HasA

Dlugroctc
makers Ard-Hes

AR-HBe

| 2 S 6 3

Monts of esposure

O Molecular Test: HBV DNA detection using PCR.

o Non-Specific Tests: Elevated liver enzymes, elevated serum bilirubin.
(E) Prevention

Active Immunization:
o
Vaccine Type: Recombinant subunit vaccine using HBSAg.
O Route: Intramuscular, typically in the deltoid.
o Schedule: Three doses at O, 1, and 6 months for adults; o, 10, and 14 weeks for
infants.
o Protection Marker: Anti-HBSAg antibody titer of 2 10 mlU/mL.
Non/Low Responders: About 5-10% do not require further vaccination.
O

Passive lmmunization:
o Hepatitis B Imnunoglobutin (HBIG): Provides temporary protection for 3-6
months.
o Administration: lntramuscular, ideally within hours but no later than 7 days after
exposure.
o Dose: 0.06 mL/kg (or 10-12 IU/kg) as a
single dose.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, No. 479

u4)
Skin & Soft Tissue Infections

Skin and Soft tissue

46. Write a short note on cutaneous leishmaniasis (3 Marks)
Answer:

Cutaneous leishmaniasis
Causative Agent o Leishmania tropica complex
Vector o Sandfly
Habitat(Protozoan) o Resides in reticuloendothelial cells
o Painless papule
O Nodular
Clinical Features
o Ulceration
o Possible disfigurement/scarring
Cutaneous Leishmaniasis (CL)- Oriental sore
o

o Leishmnaniasis Recidivans (LR)- Granulomatous reaction

granulomatous reaction in which new lesions appear years
Types
after the primary wound caused by L.tropica has been
healed
O Diffuse Cutaneous Leishmaniasis- extensive skin lesions
O
Microscopy (Amastigotes)
Diagnosis o Culture (NNN medium, Schneider Drosophila medium)
o
Montenegro Test (for delayed hypersensitivity)
o Topical Therapy (eg., paromomycin, methyl benzethonium
Treatment ointment)
o
Systemic Therapy (e.g., fluconazole, pentavalent antimony)
Characteristic
o
Chiclero Ulcer (persistent ear ulceration)
Lesions (New O Espundia (ulcerative lesions on mucous membranes, may
World Leishmania) lead to cartilageerosion)
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. S65

115) R MedEd
Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

47. What are the various infective conditions of the skin and the organism causing
them? (3 Marks)
Answer:
Superficial clinical feature Organisnms
epidermis
Ringworm or tinea Becase of their ability to utilize Dermatophytes
infection keratin, they infect keratinizedTrichophyton-infects
skin,
layers of epidermis, hair ana
nails. The skin lesions appear as hair
and nail
annular or ving-shaped pruritic,| Microsporum-infects skin
scaly with central clearing and and hair
raised edge. Epidermophyton-infects
skin and nail
Deep epidermis
Clinical feature Organism
and dermis
|Impetigo Erythematous lesions that mayS. pyogenes, S. aureus (for
|be either non-bullous or bullous bullous impetigo)
that rupture and develop into
honey-coloured crusts
Erysipelas Non-necrotizing inflammationS. pyogenes, S. aureus
of dermis and subcutaneous
tissue Lesions are painful, red,
Swollen, and indurated with a
|distinct border Patients may
also have fever and regional
|ymphadenopathy
Erythrasma Chronic infection of theCorynebacterium
keratinized layer of the minutissimum
epidermnis; lesions are dry, scaly,
itchy, and discolored (reddish
brown)
Erysipeloid Purplish-red, non-vesiculatedErysipelothrix
skin lesion with an irregular,
raised border; the lesions itch
and burn
Cellulitis Diffuse, spreading infection S. pyogenes, S. aureus
involving the deeper layers of the
dermis; lesions are ill-defined,
flat, painful, red, and swollen;
patients have fever, chills, and
regional lymphadenopathy
Skin & Soft Tissue Infections

Skin and Soft tissue

INFECTON OE
SKIN APPENDAGES
o (nfection of the hair follicle
Folliculitis/carbuncle/furuncle - caused by Staph aureus.
o lnfection of the sweat gland
* Hidradenitis- caused by Staph aureus, Streptococcus agalactiae, Bacteroides etc.
o lnfection of the sebaceous gland
Sebaceous cyst caused by Staph aureus
O lnfection of nail

$ Onychomycosis- caused by Tinea unguium and Candida albicans

* Green nail- caused by pseudomonas aeruginosa
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition,, Page No. 503

117) BMedEd
Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

48. What is the difference between HSV 1 and 2 and the laboratory diagnosis?
(3 Marks)
Answer:

Properties Herpes simplex virus 1 Herpes simplex virus 2

Common modes of Direct contact with mucosaSexual mode or vertical
transmission or abraded skin mode
|Latency in Trigeminal ganglia Sacral ganglia
Age affected Young children Young adults

Common manifestations Oral-facial mucosal lesions Genital lesions

Encephalitis and meningitis Skin lesions- below the
Ocular esions waist
Skin lesions above the Neonatal herpes
waist
Neurovirulence Less More
Drug resistance Less More
LABORATORY DIAGNOSIS
o Cytopathology
* Wright's or Giemnsa stain- reveals inclusion bodies known as Lipschultz body
formation of multinucleated giant cells known as Tzank cells having ground glass
chromatin.
o Virus isolation by
MeCoy cell line used to demonstrate diffuse rounding and ballooning of cell lines
Shell vial culture-detects antigens in cell line by IF.
O Antigen detection- by direct IF

o DNA detection by PCR and real-time PCR

o Serology By ELISA we detect antibodies against glycoprotein G.

Reference: Essentials of Medical Microbiology Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 551
< Skin & Soft Tissue Infections
Skin and Soft tissue

49. What is the classification of Herpesviruses. Short note on Kaposi Sarcoma.

(3 Marks)
Answer:
DNA VIRUS INCLUDE
o
Herpesvirus
o Smallpox virus
O Parvovirus
O HPV

Duration of replication Site of latency

Subfamily
and cytopathology Common name
Short (12-18 hours) Neurons Herpes simplex virus type 1
Cytolytic
Apha Herpes simplex virus type 2
Varicella-zoster virus (HHV
3/VZ)
Long (24 hours) Glands, kidneys| Cytomegalovirus (HHV-5)
Cytomegalic
Beta Long (>24 hours) Lymphoid Human herpesvirus 6
Lymphoproliferative tissues (T cells)Human herpesvirus
7
Variable Lymphoid Epstein-Barr virus (HHV-4)
Lymphoproliferative tissues (B cells)
Gamma
Kaposi's sarcoma-associated
|herpesvirus (HHV-s)
KAPOSI'SSARCOMA (KS)
o Cause: Caused by Human Herpesvirus s (HHV-8) infection.
O Common in: Often associated with HIV/AIDS and more prevalent in specific ethnic
groups.
O Appearance: Painless, reddish-purple or brownish skin lesions or nodules; may
affect the mouth and internal organs.
o Diagnosis: Confirmed through biopsy of affected tissue.
o Treatment: Depends on severity; includes ART for HIV, local therapies, and systemic
treatment.
o Prognosis: Varies based on subtype and overall health; manageable with early
detection and treatment.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition,, Page No. 551

KMedEd
Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

SO. Write a short note on larva migrans and larva currens. (3 Marks)
Answer
There are two main types of larval migration:
CUTANEOUS LARVAE MIGRANS (CREEPING ERUPTION)
O This type of larval migration occurs in the skin and subcutaneous tissues.
o It is primarily caused by the parasitic worm Ancyclostoma.
VISCERAL LARVAL MIGRATION
o In this form, the larva migrates to the intestine, disrupting the normal life cycle.
o It is primarily caused by Toxocara infections, although other helminths can rarely
cause it.
* Angiostrongylus cantonensis leads to eosinophilic meningitis.
* Angiostrongylus costaricensis causes abdominal infections.
LABORATORY DIAGNOSIS
o Stool Microscopy: The presence of Rhabditiform larvae is a diagnostie marker.
o Entero-test: Microscopy of duodenal aspirate.
Stool Culture: Using the agar plate technique.
o Serology: ELISA is employed to detect antibodies against crude larval antigens.
o Coproantigen: ELISA is used to identify larval antigens in stool samples.
o Molecular Testing: Real-time PCR is utilized to detect the cytochrome c Oxidase
gene and 18S rRNA in stool samples.
LARVA CURRENS (CAUSED BY STRONGYLOIDES STERCORALIS)

O Larva currens presents with gastrointestinal and cutaneous symptoms.

o Complications can lead to hyperinfection syndrome involving the central nervous
system.
o
It is characterized by its rapid rate of cutaneous spread.
LABORATORY DIAGNOSIS
o Molecular Method: Detecting larval DNA in human tissue via PCR.
o Eosinophilia: Elevated levels of eosinophils in blood and sputum can be indicative.
To reduce the risk of larval migration infections:
o Maintain personal hygiene.
o
Avoid barefoot walking in risky areas.
o Deworm pets regularly.
o Cook meat thoroughly, especially pork.
o Educate about infection risks and precautions.
Reference: Essentials of Medical Microbiology, Apurba s sastry and Sandhya Bhat, 3rd
Edition, Page No. 449

120)
Skin & Soft Tissue Infections
SKIn ana >ort tIssue

S1. Write in brief about chromoblastomycosis. (3 marks)

Answer:.

o Chromoblastomycosis is a chronic subcutaneous fungal infection characterized

by slow-growing lesions caused by certain darkly pigmented fungi. These fungi
produce distinct structures called sclerotic bodies.

Chromoblastomycosis
lntroduction Chronic subcutaneous fungal infection with slow-growing
lesions
Causative Agents o Fonsecaea pedrosoi
OF. compacta
o Phialophora verrucosa
o Cladosporium carrionii
O
Rhinocladiella aquaspersa
Clinical Presentation Various lesion types: verrucose, crusted, ulcerative, nodular,
or tuor-like
Sclerotic Bodies Brown, thick-walled, round cells (5-12 um) with internal
transverse septa
Diagnostic Feature Presence of sclerotic bodies in histopathological exams
Treatmnent Surgical removal of lesions followed by itraconazole

Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, srd
Edition, Page No. 581

121) RMedEd
Skin & Soft Tissue Infections
MedEd FARRE: Microbiology

S2. Write a short note on anthrax. (5 marks)

Answer:
Causative organism:
O Anthrax is caused by Bacillus anthracis.
Virulence Factors and Pathogenesis:
O Anthrax Toxin: Anthrax toxin is a tripartite toxin consisting of three fragments:
o Edema Factor: This active fragment functions as an adenylyl cyclase, increasing
host cell CAMP. It plays a role in causing edema and other disease manifestations
seen in anthrax.
o
Protective Factor: This binding fragment attaches to host cell receptors, facilitating
the entry of other toxin fragments into host cells.
O Lethal Factor: This fragment induces cell death by cleaving host cell MAPK
(mitogen-activated protein kinases).
o
Anthrax Capsule: B. anthracis possesses a capsule composed of polyglutamate
(unlike most capsulated bacteria that have polysaccharide capsules). This capsule
inhibits complement-mediated phagocytosis, helping the bacterium evade the
host's immune response.
Clinical Manifestations:
o Human Anthrax: Human infection occurs through various routes:
Cutaneous: This is the most common form in humans and results from spores
entering through abraded skin.
Inhalation: lnhalation of anthrax spores can lead to a more severe form of the
disease.
* Ingestion: In rare cases, ingestion of carcasses of animals that have died from
anthrax and contain spores can cause the disease, often presenting as bloody
diarrhoea
o Cutaneous anthrax: Characterized by Malignant pustule
o Pulmonary anthrax: Hemorrhagic pneumonia along with hemorrhagic mediastinitis
and meningitis.
LABORATORY DIAGNOSIS
Specimen Collection:
o Pus, Swab, or Tissue from Malignant Pustule: This is the primary specimen for
cutaneous anthrax.
o Sputum: Collected for pulmonary anthrax cases.
o Blood: Particulary important in cases of septicemia.
o Cerebrospinal Fluid (CSF): If hemorrhagic meningitis is suspected.

122)
Skin & Soft Tissue Infections
o
Gastric Aspirate, Feces, or Food: In cases of intestinal anthrax.
o Ear Lobes from Dead Animals: Useful in veterinary diagnosis.
Direct Demonstration:
o Gram Staining: B. anthracis appears as gram-positive, large rectangular rods.
Spores are usually not seen in clinical samples.
o McFadyean's Reaction: Staining technique to demonstrate the polypeptide capsule
Surrounding the bacilli.
O Direct Immunofluorescence Test (Direct-IF): Detects capsular
and cell wall
polypeptide antigens using fluorescent-tagged monoclonal antibodies.
Culture:
o Bacillus anthracis can be cultured on ordinary media. Characteristics of its colonies
include:
* On nutrient agar: Irregular, round, opaque, greyish -white colonies with a frosted
glass appearance.
3 "Medusa head appearance"; When viewed under a mieroscope, the edge of the
colony looks like locks of matted hair.
3 On blood agar: Dry, wrinkled, non-hemolytic colonies.
3 Gelatin stab agar: Growth appears as an inverted fir tree appearance due to
the liquefaction of gelatin.
O Selective media like PLET medium aid in the identification of B. anthracis colonies.
Additional Tests:
o Ascolis Thermoprecipitation Test: Useful when specimens are putrid. it's a ring
precipitation test.
Culture Smear:
o Gram Staining: "bamboo stick appearance." This means you see long chains of
gram-positive bacilli with non-bulging spores. The spores appear as empty spaces
in the chain.
o Spores: Spores of Bacillus anthracis can be demonstrated using hot malachite
green (Ashby's method).
Molecular Diagnosis:
o Polymerase Chain Reaction (PCR): Specific primers can be used in PCR to target
genes associated with B. anthracis.

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 534

103 MedEd
Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

S3. Write a short note on Varicella zoster infection. (S marks)

Answer:
o Varicella is herpesvirus 3 and causes two main diseases
$ Chickenpox: generally affects children
Shingles or zoster: due to reactivation of latent varicella virus.
CHICKENPOX
Pathogenesis:
O Varicella -zoster virus (VZV) enters the body through the upper respiratory mucosa
or conjunctiva via aerosol or contact transmission.
o it then disseminates from the initial site of infection to various target sites, including
the skin (leading to rashes), respiratory tract (shedding in respiratory secretions).
and neurons (where it undergoes latency).
Clinical Manifestations:
o The incubation period for chickenpox is typically 10-21 days (2-3 weeks).
O Rashes are the primary manifestation, and they are vesicular in nature.
o Rashes are centripetal in distribution, usually starting on the face and trunk
before spreading to involve the flexor surfaces. They tend to spare the distal parts
of the limbs.
o The distribution of rashes is bilateral and diffuse.
o Rashes appear in multiple crops, with lesions in various stages of evolution, including
maculopapules, vesicles, pustules, and scabs, all potentially present at the same
time.
O Fever tends to appear with each crop of rashes.
Complications:
o Secondary Bacterial Infections of the Skin: These can occur when the skin lesions
from chickenpox become secondarily infected by bacteria.
o Central Nervous System (CNS) Involvement: This includes conditions cerebellarlike
ataxia, encephalitis, and aseptic meningitis, and it's more common in children.
o Varicella Pneumonia: This is a severe complication that occurs more commonly in
adults than in children.
o Reye's Syndrome: This syndrome can develop as a result of VzV infection, especially
when aspirin is taken during the illness. it's characterized by fatty degeneration
of the liver.
o Chickenpox in Pregnancy: Mothers are at risk of developing varicella pneumonia,
while the fetus is at risk of congenital varicella syndrome, which can lead to skin
lesions and limb hypoplasia if the infection occurs in early pregnancy.
Skin & Soft Tissue Infections

Zoster:
o Typically occurs due to the reactivation of latent Varicella-Zoster Virus (VZ)
in older individuals (usually over 6o years old), immunocompromised people, or
occasionally in healthy adults.
o Painful Onset: Zoster starts with severe pain in a specific area of the skin or
mucosa that is supplied by one or more groups of sensory nerves and ganglia.
o Unilateral Rashes: The characteristic feature of zoster is the development of
unilateral and segmental rashes, localized to the area of skin supplied by the
affected nerves.
o Common Nerve involvement: The ophthalmic branch of the trigeminal nerve is
often involved, but zoster can affect various parts of the body, with the head,
neck, and trunk being the most commonly affected sites.
Complications of Zoster can include:
o Post-Herpetic Neuralgia: involves persistent pain at the site of the rash that can
last for monthS.
o Zoster ophthalmicus: When the eye area is affected, it can lead to painful skin
rashes around the eye.
o Ramsay Hunt Syndrome: A triad of synptoms: ipsilateral facial paralysis, ear
pain, vesicles on the face, tympanic membrane, and external auditory meatus.
o Visceral Diseases: such as pneumonia,
o Recurrent or Chronic Zoster: This is more common in individuals with HIV infection.
Laboratory diagnosis:
o Specimen Collection: Common specimens for Vzv testing include vesicular lesions,
scabs, and maculopapular lesions. These samples are collected from the affected
areas of the skin.
o Cytopathology (Tzanck Smean): Giewmsa staining of serapings from the base of skin
ulcers (Tzanck smear) can reveal characteristic multinucleated giant cells.
VZV-Specific Methods:
* Direct lmmunofluorescence Staining: it is useful for direct antigen detection in
clinical specimens.
<>
ELISA (Enzyme-Linked Immunosorbent Assay): ELISA tests can detect specific
lgM and lgGantibodies against VZV in a patient's blood serum.
* PCR is used to detect specific genes of VZV.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. S54

125 MedEd
Skin & Soft Tissue Infections
MedEd FARRE: Microbiology

s4. Write a short note on measles. (5 marks)

Answer:
o Measles is a highly contagious childhood disease caused by the measles virus, which
belongs to the Parawmyxoviridae family.
O Transmission: Measles is primarily transmitted through respiratory droplets when
an infected person coughs or sneezes. It can also spread through smal-particle
aerosols that can remain suspended in the air for longer periods
Pathogenesis:
o Local Multiplication: After transmission, the virus initially multiplies in the
respiratory tract of the infected individual.
O Lymph Node Involvement: The virus then enters the regional lymph nodes.
o
Primary Viremia: From the lymph nodes, the virus enters the bloodstream through
infected monocytes, leading to primary viremia.
O Reticuloendothelial System: The virus further multiplies in the reticuloendothelial
system
o
Secondary Viremia: The virus spills over into the blood again which allows the virus
p
to disseminate to various sites in the body.
o Target Sites: Measles virus predominantly infects and replicates in the epithelial
surfaces of the body, including the skin, respiratory tract, and conjunctiva.
CLINICAL FEATURES
1. Prodromal Stage (Days 1-4):
o This initial stage lasts for about 4 days and typically begins around the 10th day
after infection.
o Fever is the first symptom, appearing on day 1 of this stage.
o Koplik's spots, which are pathognomonic for measles, appear after two days
following the onset of fever. They manifest as white to bluish spots surrounded by
erythema and are usually seen on the buccal mucosa near the se cond lower molars.
o Non-specific symptoms may include cough, coryza (inflammation of the mucous
membranes in the nose), nasal discharge, eye redness, diarrhea, or vomiting.
2. Eruptive Stage (Days s-8):
o Maculopapular rashes develop after4 days of fever, typically on the 14th day
after infection.
o
The rashes usually start behind the ears and then spread to the face, arms, trunk,
and legs.
o They fade in the same order after about 4 days from their onset.
o Notably, rashes are typically absent in individuals with HIV infection.
Skin & Soft Tissue Infections

3. Post-Measles Stage:
o This stage is characterized by weight loss and weakness.
o Some individuals may fail to fully recover and experience a gradual deterioration
of health, potentially leading to a chronic illness.
Complications:
o Giant-cell pneumonitis (Hecht's pneumonia) in immunocompromised children and
HIV-infected individuals.
o Acute laryngotracheobronchitis (croup).
o Diarrhea, which can result in malnutrition, including vitamin A deficiency.
o Subacute sclerosing panencephalitis (SSPE) is a progressive neurological disorder
and the most important CNS complication associated with measles.
O Other CNS complications include post-measles encephalomyelitis and measles
inclusion body encephalitis.
Laboratory diagnosis:
o Specimen collection: Casopharyngeal swabs, swabs from the lesions, blood, and
respiratory secretions are taken.
o Antigen Detection: Measles antigens within infected cells can be directly
detected using anti-nucleoprotein antibodies. This is done through a direct
immunofluorescence test.
Antibody Detection:
o The detection of measles-specific antibodies is an important diagnostic approach.
o Measles-specific tgM antibodies can be detected in serum or oral fluid, and a
four-fold rise in lgG antibody titer between acute and convalescent-phase sera is
considered significant.
o Demonstration of elevated anti-measles antibody titers in the cerebrospinal fluid
(CSF) is diagnostic of subacute sclerosing panencephalitis (SSPE).
o ELISA (enzyme -linked immunosorbent assay) is a commonly used test that employs
recombinant measles nucleoprotein (NP) antigens.
Reverse-Transcription PCR (RT-PCR):
o RT-PCR s a highly seinsitive and specific method for detecting measles-specific
RNA, Such as the nucleoprotein (N) gene.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 559

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MedEd FARRE: Microbiology

S5. Write a short note on Rubella. (S marks)

Answer
O Rubella belongs to the family Togaviridae and is responsible for the disease German
measles.
Transmision and Pathogenesis:
o Rubella virus spreads from person to person via respiratory droplets, primarly
through the upper respiratory mucosa.
o The virus replicates locally in the nasopharynx before spreading to the lymph
nodes.
o Viremia (presence of the virus in the bloodstream) typically develops after 7-9
days, coinciding with the appearance of antibodies and rashes, suggesting an
immunological basis for the rash.
Clinical Manifestations:
o The incubation period for rubella is about 14 days, with a range of 12-23 days.
o Subclinical (asymptomatic) infections may occur
O
ln children, rashes are often the first manifestation of the disease.
O
ln older children and adlts, a 1 to S-day prodrome may precede the rash,
characterized by low-grade fever, malaise, and upper respiratory synmptoms.
o The rashes are generalized and maculopapular (small, raised, red spots) in nature.
They typically start on the face, extend to the trunk and extremities, and disappear
within 3 days.
o Lymphadenopathy (swollen lywmph nodes) is a notable feature, particularly in the
occipital and postauricular regions.
o
Forchheimer spots, pin-head-sized petechiae, may be seen on the soft palate and
uvula, usually coinciding with the onset of the rash.
Complications:
o Arthralgia (joint pain) and arthritis (joint inflammation) are common complications
in adults, especially women.
o Thrombocytopenia (low platelet count) and encephalitis (brain inflammation) are
rare but possible complications.
Laboratory Diagnosis:
o Virus isolation: Monkey cell lines
* For early detection, we should use a shell vial technique
o Serology
* ELISA to detect lgM and lgG

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* lgG avidity test should be done to differentiate past and active disease.
o Molecular test
RT-PCR to detect viral-specific RNA.
PREVENTION
Rubella Vaccine:
o The rubella vaccine, often referred to as RA 27/3, is a live attenuated vaccine
prepared from a human diploid fibroblast cell line.
o It is available as a single vaccine or in combination with vaccines for mumps and
measles (MMR vaccine).
Vaccination Schedule:
o
A single dose (o.5 mL) of the rubella vaccine administered subcutaneously.
is

o Immunity following vaccination typically lasts for 14-16 years, possibly lifelong.
Reference: Essentials of Medical Microbiology., Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. s62

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MedEd FARRE: Microbiology

S6. Write a short note on mycetoma? (S marks)

Answer:
o Mycetoma is a chronic granulomatous infection of the subcutaneous tissue.
Types of Mycetoma and Causative Agents:
O Mycetoma can be caused by either fungal agents (eumycetoma) or bacterial agents
(actinomycetoma). These two types differ from each other in various properties,
including the color of the granules or grains, and clinical manifestations.
o There is a third category called botryomycosis, which is a mycetoma -like condition
caused by certain bacteria like Staphylococcus aureus.
Pathogenesis:
o
Mycetoma typically begins when the causative agents enter the skin or subcutaneous
tissue through accidental trauma, such as thorn pricks or splinter injuries.
o The disease then progresses slowly, initially forming wmicro-abscesses due to the
inflammatory response filled with polymorphonucleair leukocytes. These abscesses
are later replaced by chronic granulomatous tissue within the skin and subcutaneous
tissues.

Eumycetoma Actinomycetoma
Black granules: White to yellow granules:
o Madurella mycetomatis O Nocardia species
o Actinomadura madurae
White granules:
O
Aspergillus nidulans Pink to red granules:
o
O Fusarium species Actinomadura pelletieri

Characteristic Eumycetoma Actinomycetoma

Causative Organism Fungal (eumycetes) Bacterial (actinomycetes)
Common Pathogens Madurella, |Actinomadura, Nocardia, etc.
Pseudallescheria, etc.

Clinical Presentation Slowly progressing. slowly progressing,

painless swelling and sinus painless swelling and sinus
formation |formation

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Skin and Soft tissue

Infection Site |Affects subcutaneous Primarily affects

tissues, especially the feet subcutaneous tissues but
and legs can involve other parts of
the body
Microscopic Features Characteristic fungal grainsSulfur granules and
(sclerotia) in tissue bacterial filaments in
tissue.

Diagnosis Clinical examination, Clinical examination,

imaging, fungal culture, imaging, bacterial culture,
and molecular tests and molecular tests.
Treatment Antifungal medications Antibiotics
(e.g., itraconazole, (e.g, trimethoprim
amphotericin B) sulfamethoxazole).
o Clinical manifestations of mycetoma are characterized by a specific triad of
Symptoms, which include:
o Tumor-like swelling (Tumefaction): Refers to localized, abnormal swelling or masses
that develop in the affected area.
o Discharging sinuses: Mycetoma often leads to the formation of sinuses, which are
wound-like openings on the skin. These sinuses are a hallmark of the condition.
o Discharge-containing granules: The discharge from these sinuses contains
characteristic granules, which are often visible to the naked eye. These granules
can vary in color depending on whether the mycetoma is caused by fungal
(eumycetoma) or bacterial (actinomycetoma) agents.
o The most commonly affected part of the body is feet.
LABORATORY DIAGNOSIS
Specimen collection:
o Cean the lesion and take the discharge coming from the pus along with granules.
Direct examination:
o Clean and crush the granules between slides and examine them.
a. Macroscopic appearance: See the size, shape, and colour of the granule.

o KOH mount: Stain the granule and look for chlamydospores

o For actinomycetoma: stain with gram stain. Gram ve bacilli are seen as acid-fast
stains for Nocadia.
o Histopath examination: Palisading arrangement of hyphae seen in eumycetoma
while actinomycetoma shows filamentous bacteria.

MedEd
< Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

Culture:
Granules obtained from deep biopsies are cultured in
o Combination of fungal media like Sabouraud dextrose agar (SDA) and bacteriological
media such as Lowenstein -Jensen media should be utilized for culturing.
o Actinomycetoma is identified by assessing urease activity, resistance to acid
fast staining, and their capacity to break down media-containing substances like
casein, tyrosine, and xanthine.
Treatment:
Surgically removing the affected lesion, followed by
O Eumycetoma, antifungal medications like itraconazole or amphotericin B
o Actinomycetoma is treated with antibiotics, often following the Welsh regimen,
which combines amikacin with cotrimoxazole.
Reference: Essentials of Medical Microbiology, Apurba s sastry and Sandhya Bhat, 3rd
Edition, Page No. S79

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Skin and Soft tissue

S7. Write in brief about Rhinosporidiosis. (3 marks)

Answer:
O
Rhinosporidiosis isa chronic condition characterized by the presence of large, fragile
polyps primarily in the nasal cavity, although it can also affect the conjunctiva,
ears, larynx, bronchus, and genitalia.
o This condition is caused by Rhinosporidiun secberi, considered an aquatie protistan
parasite rather than a fungus.
Source:
o The main source of infection
is stagnant water, particularly contaminated ponds
and rivers.
o Infection occurs when individuals inhale spores while bathing in these contaminated
water sOurces.
Laboratory diagnosis:
o Specimen: Tissue biopsy of the polyp
O
Histopathological examination
o Revealing
distinctive spherules that contain numerous endospores
o Mucicarmine stain is effective for visualizing these structures. The primary
treatment for rhinosporidiosis involves radical surgery with cauterization.
Treatment:
o Surgery
Dapsone has also shown effectiveness in managing the condition.
O

O The condition is prone to recur.

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 582

133) KMedEd
Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

S8. Write a note on Sporotrichosis. (5 marks)

Answer:
o Sporotrichosis, also known as Rose Gardner's disease, manifests as subcutaneous
noduloulcerative lesions and is caused by a thermally dimorphic fungus called
Sporothrix schenckit.
Pathogenesis
o The pathogenesis of sporotrichosis begins with the introduction of S. schenckii
spores into the skin, often through minor injuries like thorn pricks or splinters.
o The fungus secretes enzymes, including serine proteinase and aspartic proteinase.,
which aid in local tissue invasion.
o s. schenckii has a tendency to spread along the lymphatic vessels.
Clinical manifestations
o It isa chronic subcutaneous pyogranulomatous disease.
O
incubation period of approximately three weeks.
o There are various clinical types:
> Lymphocutaneous type (most common): characterized by noduloulcerative
lesions that develop along the lymphatics. This pattern of spread is known as
the sporotrichoid pattern,
» Enlargement of lymph nodes occurs, which become suppurative, indurated, and
feel cord-tike upon palpation.
o Other clinical types, though rare, include:
* Osteoarticular type: Typically found in alcoholics.
* Pulmonary type: Develops after inhaling spores, often in individuals with
underlying chronic obstructive putmonary disease (COPD).
Disseminated
sporotriCs Occurs in immunocompromised patients, such as
those with AIDS.

* Fixed cutaneous type: Characterized by a single nodule that is less progressive

and does not spread via lymphatics.
Laboratory diagnosis
o Direet Microscopy: Specimens like pus, aspirate from nodules, or swabs from ulcers
can be examined using a KOH mount or calcofluor staining. These methods reveal
elongated yeast cells.
o Histopathological Staining: Tissue sections can be stained, for example, with
hematoxylin and eosin. This staining reveals cigar-shaped asteroid bodies, which
< Skin & Soft Tissue Infections
Skin and Soft tissue
consist of a central basophilic yeast cell surrounded by radiating extensions of an
eosinophilic mass.
o This mass is composed of antigen-antibody complexes and is referred to as the
Splendore-Hoeppli phenomenon. This phenomenon also observed in other fungal
infections like zygomycosis, candidiasis, aspergillosis, and blastomycosis.
O Culture: This is the most definitive diagnostic method. Specimens are inoculated onto
Sabouraud dextrose agar (SDA) and blood agar in duplicate and then incubated at
both 25°C and 37°C. This is because S. schenckii is a dimorphic fungus. At 25°C,
it produces a mycelial form with slender, delicate hyphae and conidia arranged in
a flower-like pattern. At 37°C, it produces a yeast form, characterized by moist,
creamy white colonies that turn brown -black in 10-14 days.
o Serology: A latex agglutination test can detect serum antibodies in patients with
the extracutaneous form of the disease, but it may not always provide a definitive
diagnosis.
o Skin Test: This test may demonstrate a delayed type of hypersensitivity reaction
against the sporotrichin antigen.
Treatment
O ltracOnazole the DOC.
Other conditions that show sporotrichoid pattern of spread are:
o Nocardia
o Mycobacterium inarinum
o Leishmania brasiliensis
o Coccidioidomycosis
OAnthrax
o Tularemia
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 580

135) (KMedEd
 MedEd FARRE: Microbiology

59. A 45-year-old male construction worker presents to the emergency department

with severe pain, swelling, and discoloration of his right lower leg. He reports a
recent injury at the construction site, where a metal rod punctured his leg. The
injury occurred three days ago, and he initially cleaned the wound with water
but did not seek medical attention. Over the past 24 hours, the pain has become
excruciating, and he has noticed a foul-swmelling discharge from the wound. On
examination, the patient's right lower leg is swollen and tense, with marked
erythema (redness) and erepitus (crackling sound) on palpation. The wound site
is covered in dirty, necrotic tissue, with a foul odor. (10 marks)
(A) What is the likely diagnosis? Enumerate the causes of this condition.
(B) Write the Pathogenesis and clinical features of Clostridium pertringens.
(C) Write the laboratory diagnosis of ctostridium perfringens gas gangrene

Answer:
(A) The probable diagnosis is Gas gangrene. Common causes of this are
o Polyicrobial - most common
Clostridium perfringens- most common among polymicrobial
o

o Cnovyi
o Csepticum
(B) Pathogenesis: Clostridium produces various toxins which are responsible for its
virulence
o Alpha (o) Toxin: This toxin is responsible for myonecrosis and hemolysis
* It has both sphingomyelinase and phospholipids C activity.
> It activates platelet adhesion by binding to Gpllb/la and causes vessel occlusion.
o Beta (B) Toxin
o Epsilon (E) Toxin: Epsilon toxin affects the central nervous system
O lota (O Toxin: lota toxin is involved in causing enteritis necroticans
o These are the major toxins responsible for its pathogenesis.
CLINICAL MANIFESTATIONS

Clostridial Wound Infections:

o Simple Wound Contamination
o Anaerobic Cellulitis: Involvement of the fascial plane with minimal toxin release
and no muscle invasion.
o Anaerobic Myositis (Gas Gangrene): Invasion of muscle tissue leading to gas
accumulation in the muscle compartment with significant toxin production.

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< Skin & Soft Tissue Infections

Skin and Soft tissue

Clostridial Enteric Infections:

o
Food Poisoning: Caused by the type A enterotoxin, typically resulting from
consumption of improperly cooked contaminated meat.
o Enteritis Necroticans (Gas Gangrene of the Bowe): A life-threatening condition
involving necrosis of the jejunum and gas in the tissue plane
Necrotizing Enterocolitis
o Gangrenous Appendicitis: Involvement of the appendix.
Laboratory diagnosis
Specimen Collection: Necrotic tissues, muscle fragments, and exudates frown the
deeper part of the wound where the infection is more active.
o Transport: Specimens should be placed into Robertson's cooked meat broth and
transported immediately to the laboratory for analysis.
o Direct Microscopy: The characteristic feature is the absence of neutrophils in
infected tissues, the presence of thick, stubby, boxcar-shaped, gram-positive bacilli
without spores is suggestive of.
Culture Characteristics: To identify C. perfringens, culture plates should be incubated
anaerobically at 37°C for 2 days. Specific characteristics include:
o Target Hemolysis: On blood agar, C. perfringens produces a characteristic pattern
of hemolysis with an inner narrow zone of complete hemolysis (due to -toxin)
surrounded by a wider zone of incomplete hemolysis (due to alpha toxin).
O Nagler's Reaction: C. perfringens exhibits opalescence surrounding the streak line
On egg yolk agar due to lecithinase activity of a-toxin. This reaction can be
inhibited by incorporating anti-a-toxin into the wmedium.
o Reverse CAMP Test: A positive test is indicated when C. perfringens is streaked
over the center of a blood agar plate, and Streptococcus agalactiae is streaked
perpendicular to it, resulting in an enhanced zone of hemolysis (arrow-shaped)
pointing towards C. perfringens.
o Heat Tolerance: C. perfringens can grow in RCM broth incubated at 4s°C for 4-6
hours, distinguishing it from other organisms in the specimen.
o Litmus Milk Test: C. perfringens produces a "stormy clot reaction'" in litmus milk
due to the fermentation of lactose, producing acid and vigorous gas.
o Automated Methods: Modern techniques like MALD-TOF can be used to identify.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. S28

RMedEd
< Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

60. A 32-year-old Female complained of a painful skin lesion on her right forearm
that has been progressively worsening over the past few days. She reports redness,a
Swelling, and severe tenderness at the site. she also mentions that she had
similar episode on her leg a few months ago. The center of the lesion appears to
be filled with pus whose laboratory studies reveal Staphylococcus aureus positive.
(A) What are the virulence factors of S. aureus? (10 marks)
(B) Enumerate some common clinical manifestations of S. aureus
(C) Write the laboratory diagnosis.
Answer:
l(A) VIRULENCE FACTORS

Cell wall-associated factors Toxins

o Peptidoglycan Membrane active toxins:
o Teichoic acid o Hemolysins-alpha, beta, gamma, delta
o Cell surface adhesins, e.g. clumpingo Leukocidin (or Panton-valentine toxin)
factor Protein A o Epidermolytic toxin (exfoliative toxin)
Enterotoxins Toxic shock syndrome toxin
Extracellular enzymes:
o Coagulase
o Heat stable thermonuclease
o
Deoxyribonuclease
o Staphylokinase (fibrinolysin)
o Others-hyaluronidase, lipase, and
protease
Cell wal-a5s0ciated factors
o Peptidoglycan layer: It is thick, provides rigidity and has endotoxin-like activity.
o Teichoic acid: It helps in attaching the cocci to the wmucosa and inhibits opsonisation.
o Cell surface adhesins: which include bound coagulate, fibronectin binding adhesion
etc.
o Protein: A has anti-complementary, inhibits opsonisation and induces platelet
damage
& It also binds to the Fc portion of lgG and is responsible for co-agglutination
reaction.
O
Microcapsule inhibits phagocytosis.

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Hemolysins:
o Staphylococcus aureus produces four distinct hemolysins: a, B.y, and 8 hemolysins.
o These toxins damage cell membranes and primarily act on red blood cells (RBCS),
leading to hemolysis.
o They have various actions, including dermonecrotic, cytotoxic, neurotoxic, and
leucocidal activities.
Leukocidins/ Panton-Valentine Toxin (PV Toxin):
O Also known as Panton-Valentine toxin, it acts synergistically with y-hemolysin to
damage leukocytes, RBCS, and wmacrophages.
o PV toXin is associated with MRSA (methicillin -resistant Staphylococcus aureus)
strains and is linked to community-acquired infections.
Synergohymenotropie Toxins:
or-hemolysin and PV toxin are referred to as synergohymenotropic toxins.
o lndividually, they are not active, but when combined, they produce hemolytic and
leukocidal activities.
Epidermolytic/Exfoliative Toxin (ET):
o This tOxin is responsible for staphylococcal scalded skin syndrome (SSss).
o It consists of two proteins: ET-A (chromosomal, heat-stable) and ET-B (plasmid
coded, heat-labile).
o sSsS can manifest as blisters, bullae, or exfoliation of the outer epidermal layer
of the skin.
Enterotoxin:
o These toxins are preformed and can act rapidly, leading to a short incubation
period (1-6 hours).
o They can be categorized into 15 serotypes, with Type A being the most common
cause of food poisoning.
Toxic Shock Syndrome Toxin (TSST):
o
TSST is responsible for toxic shock syndrome (TSS) and has two subtypes: TSST-1
and TSST-2.
o Both subtypes act as superantigens, stimulating T-cells non-specifically and causing
excessive cytokine production (cytokine storm).
o TSS can present with fever, hypotension, mucosal hyperemia, vomiting, diarrhea,
confusion, myalgia, abdominal pain, and erythematous rashes.

3 RoMedEd
Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

EXTRACELLULAR ENZYMES
o Coagulase:
*S. aureus secretes coagulase, a unique enzyme that activates prothrombin in the
host's blood.
This activation leads to the conversion of fibrinogen to fibrin, resulting in the
clotting or coagulation of blood.
<•
The fibrin clot formed around the bacteria can protect them from phagocytosis
and other host defense mechanisms.
The tube coagulase test is a key diagnostic test used to identify S. aureus based
on its ability to cause coagulation.
o Heat-Stable Thermonucleases and DNase
o Staphylokinase (Fibrinolysin):
O Hyaluronidase:
o
Lipases and Phospholipases:
PATHOGENESIS OF
S. AUREUS INFECTIONS
Colonization:
o aureus initially colonizes various body surfaces, including the anterior nares
S.
(nose), oropharynx, axilla, and perineal skin.
Introduction to Tissue:
o The bacteria are introduced into tissues through minorabrasions or instrumentation.
o Adhesion to tissue surfaces is mediated by adhesins such as clumping factor and
collagen-binding adhesion.
Invasion:
os.
aureus can invade tissues by producing enzymes like serine proteases,
hyaluronidases, thermonucleases, and lipases.
o These enzymes facilitate bacterial survival and local spread within tissue.
Evasion of Host Defenses:
o s. aureus employs various mechanisms to evade the host's immune defenses.
o This includes anti-phagocytic activity through microcapsules and protein A,
inhibition of leukocyte migration, and intracellular survival inside endothelial cells.
MetastaticSpread:
o S. aureus can spread to distant sites via hematogenous (bloodborne) dissemination.
Common infection caused by S.aureus:
O Folliculitis
o Carbuncle
o lmpetigo

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o Botrowmycosis
o Abscess
o Ventilator-associated pneumonia
o Sepsis
o Infective endocarditis
O Toxic shock syndrome
LABORATORY DIAGNOSIS
Sample Collection:
o The choice of the specimen depends on the nature of the infection but cowmmonly
includes pus, wound swabs, sputum, midstream urine, and blood.
o
For blood cultures, automated blood culture bottles are preferred.
Direct Smear Microscopy:
o Gram staining of pus or wound swabs typically reveals pus cells along with gram
positive cocci arranged in clusters. This is a characteristic feature of Staphylococcus
aureuS.
Culture:
o Nutrient agar- colonies are circular, smooth, convex, opaque, and easily emulsifiable.
Most strains produce goldenyellow non-diffusible pigments.
o Blood agar shows colonies similar to those on nutrient agar, often surrounded by
a narrow zone of B-hemolysis.
o On MacConkey agar, small pink colonies are produced due to lactose fermentation.
o Liquid media like peptone water result in uniform turbidity.
o Selective media containing salt (e.g.. Mannitol salt agar) can be used to isolate
staphylococci when they are expected to be present in low numbers or mixed with
other bacteria.
Biochemical Tests for ldentification:
o Catalase Test: Staphylococci are catalase -positive, which distinguishes them from
catalase -negative streptococci.
Differentiating S. aureus from Coagulase-Negative Staphylococci (CONS):
o Coagulase Test: The coagulase test is the most common biochemical test used to
differentiate S. aureus from CoNS.
o petection of Protein A: Protein A is a surface protein found on S. aureus but not
On CoNS. It can also be used for identification.

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. S11

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MedEd FARRE: Microbiology

61. A 38-year-old male presents with a painful, red, and swollen right lower leg.
He had a low-grade fever (100.4°F or 38°C). Physical examination revealed a
spreading area of erythema with a well-defined border on his right shin. The
affected area was warm to the touch and tender.No pus or abscess was palpable.
A diagnosis of streptococcal cellulitis was made after laboratory investigation.
(A) Write the classification of streptococci. (10 marks)
(B) What are the virulence factors of S.pyogenes?
(C) Write in brief about common clinical manifestations of S.pyogenes
(D) Write the laboratory diagnosis
Answer:
(A)
o
Alpha (o)-Hemolysis: Partial lysis of red blood cells (RBC), creating a small zone
of greenish discoloration surrounding the bacterial colonies.
o Beta (B)-Hemolysis: Beta-hemolysis occurs due to complete lysis of RBCs, resulting
in a wide zone of lysis around the colonies. Eg-Streptococcus pyogenes (Group A
Streptococcus)
o Gamma (r)-Hemolysis: There is no hemolysis observed around the colonies, and
therefore, there is no change in the color of the agar. Enterococcus is an example
of a bacterium that exhibits gamma-hemolysis.
Streptococci

Aerobes and facultative Obligate anaerobes

anaerobes

Peptostreptococci
Hemolysis

Alpha- hemolytic Beta-hemolytic Gamma-hemolytic

Pneumococcus and
viridans streptococci 20 serogroups (A to EnterococcUs
Vexceptl and J)

Group-A- streptococcus

Serotypes based on
M protein and emm
gene

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Additional Classification and Typing Methods:

O Lancefield: Based on the presence of the C-carbohydrate in the cell wall.
o Griffith Typing: Within Group A Streptococcus, more than 150 serotypes have
been identified based on the M protein present in their cell wall.
o Genotyping: Genotyping of Group A streptococci is based on the emm gene which
encodes the M protein.
L(B) VIRULENCE FACTORS

Cell Wall Antigens:

o Lipoteichoic Acid: Helps in adhesion to pharyngeal epithelial cells and other host
cells and proteins, such as fibronectin.
o C-Carbohydrate Antigens: Gioup-specific antigens that form the basis of Lancefield
grouping.
o M Protein: The principal virulence factor of Group A Streptococcus, which inhibits
complement-mediated opsonization, complexes with fibrinogen, and plays a role
in streptococcal toxic shock syndrome.
o Capsule: Some strains of Group A Streptococcus are capsulated with hyaluronic
acid, which is antiphagocytic and facilitates colonization.
Toxins:
o Hemolysins: Beta-hemolytic streptococci produce two hemolysins, streptolysin -O
and streptolysin-S, which cause RBC mnembrane lysis, resulting in complete beta
hemolysis.
o Streptococcal Pyrogenic Exotoxin (Spe): Responsible for the pathogenesis of certain
streptococcal infections, such as scarlet fever, necrotizing fasciitis, and toxic shock
syndrome. It can be typed into distinct subtypes, such as SPE-A, B, and C, and
acts as a superantigen.
Enzymes:
o
Streptokinase (Fibrinolysin): Activates plasminogen to plasmin, breaking down the
fibrin barrier around the infected site and facilitating the spread of infection. It
can also be used therapeuticaly in the treatment of thromboembolic disorders.
o Streptodornase (DNase): Breaks down DNA, helping liquefy thick pus and making
exudates serous. Anti-DNase B antibodies can be used for retrospective diagnosis
in certain infections.
MANIEESTATIONS
C) CLINICAL
Suppurative Infections:
Respiratory Infections:
o Streptococcus pyogenes is a common cause of pharyngitis (sore throat)
o It can lead to infections such as scarlet fever, pneumonia, or empyema.
Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

Superficial Skin and Soft Tissue infections:

o Impetigo (Pyoderwma): A superficial skin infection, primarily caused by Group A
Streptococcus.
o Cellulitis and Erysipelas: Cellulitis involves the skin and subcutaneous tissues, while
erysipelas is characterized by red, swollen, and tender skin with a "peau d'orange'"
texture, often seen on the face and lower extremities.
Deep Soft Tissue Infections:
o Necrotizing Fasciitis: A severe infection involving the superficial and/or deep fascia,
invading muscles. It can occur due to skin trauma or gastrointestinal tract breach,
and it progresses rapidly, causing severe pain and systemic symptoms.
Toxic shock syndrome
o Characterized by hypotension with more than 2 organ involvement and streptococcus
positive in blood.
Puerperal sepsis
D) LABORATORY DIAGNOSIS

Specimen Collection and Transport:

o Common specimens include pus swabs, exudates, and blood.
o Blood cultures are useful in streptococcal toxic shock syndrome (TSS).
o Throat swabs are suitable for diagnosing pharyngitis.
Direct Smear Microscopy:
o Gram staining of pus or wound swabs shows gram-positive cocci in chains
Culture:
o Specimens are incubated on various media at 37°C with5-10% CO,.
o s. pyogenes is fastidious and primarily grows on media enriched with blood,
serum, or carbohydrates.
o Blood agar shows small colonies (0.5-1 mm) with wide zones of B-hemolysis.
Biochemical Tests for ldentification:
o
Catalase test: Streptococci are catalase -negative, distinguishing them from
catalase -positive staphylococi.
o Bacitracinsensitivity testing: Group A Streptococcus is sensitive to bacitracin
(0.04 with a zone of inhibition (useful for rapid diagnosis).
U disk)

o Automation using systems like VITEK and MALDI-TOF can also identify GAS.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. S20
Skin & Soft Tissue Infections

Skin and Soft tissue

62. A 32-year-old man presented to the OPD with a complaint of having 3 circular
regions of hypopigmentation on the skin along with anaesthesia to the affected
skin area. You observe the man to have characteristic leonine fancies and make
a diagnosis of X. (10 marks)
(A) What is the diagnosis?
(B) Write the classification and the difference between 2 major subtypes
(C) Write the complications.
(D) Write it's laboratory diagnosis
Answer:
(A) The most probable diagnosis is Leprosy caused by Mycobacterium leprae.
(B)

Ridley-Jopling classification
o Lepromatous leprosy (LL)
O Borderline Lepromatous leprosy (BL)
o Borderline leprosy (BB)
o Borderline tuberculoid leprosy (BT)
o Tuberculoid leprosy (TT)

Characters Lepromatous leprosy (LL) Tuberculoid leprosy (T)

Bacillary load Multibacillary Paucibacillary
Bacteriological index 4-6t O-1+

Skin lesions |Many, symmetrical Margin One or few, asymmetrical

are irregular Lesions that Margin is sharp Lesions
appear as: appear as hypopigmented,
O Multiple nodules annular macules with
(lepromata) elevated borders Tendency
towards central clearing
o Plaques and xanthoma
like papules
O Leonine facies and
eyebrow alopecia
Nerve lesion O Nerve lesions appear late o Early anesthetic skin lesion,
o Hypoesthesia is a late sign o Enlarged thickened nerves,
O Variable nerve palsies O Nerve abscess seen

ROMedEd
Skin & Soft Tissue Infections
MedEd FARRE: Microbiology

CMI Low Normal

Lepromin test Negative Positive
Humoral immunity Exaggerated Normal
Clinical classification:
o Paucibacillary leprosy: Should fulfill all the eriteria -() 1 to s skin lesions, (i) no
nerve involvement, and (iti) slit-skin smear-negative for lepra bacilli
o Multibacillary (MB) (eprosy: Should fulfill any one of the criteria-() >s skin lesions;
or (i) nerve involvement (neuritis); or (i) slit-skin smear positive for lepra bacilli.
(C) COMPLICATIONS OF LEPROSY
Deformities:
O Nerve damage leads to muscle weakness or paralysis.
o Direct effects of the disease process, result in issues like facial deformities or
eyebrow loss.
Common deformities in leprosy include:
o Facial Deformities: These may include leonine facies (a lion -like appearance),
sagging of the face, loss of eyebrows or eyelashes, saddle nose (flattening of the
nose bridge), corneal opacity (clouding of the eye's surface),
O
Hand Deformities: These can manifest as claw hands (abnormal hand posture
resembling a claw) and wrist drop (inability to extend the wrist and fingers).
o Foot Deformities: Foot-related deformities may include foot drop (inability to
lift the front part of the foot), clawing of the toes, inversion of the foot (turning
inward), and plantar ulcers (ulcers on the sole of the foot).
Lepra reaction

Type 1 Reaction Type 2 Reaction (ENL)

Predominant Type o Borderline Lepromatous o Lepromatous Leprosy,
and Borderline especially in multibacillary
Tuberculoid leprosy Cases
Immunological Basis o Delayed-type o Immune complex
Hypersensitivity (DTH) mediated reaction
response against
Mycobacterium leprae
antigens

146)
< Skin & Soft Tissue Infections

clinical Features O lnflammation and o Painful and tender nodules

swelling of existing skin or papules on the skin.
lesions. o
Systemic symptoms such
o New lesions may appear. as fever, malaise, and joint
pain.
o Sometimes affects internal
organs.
Histopathological O lncreased cell-mediatedo lmmune complex deposits
Changes immunity with granuloma in the skin and blood vessels.
formation.
Management o Anti-inflammatory O Prednisone or other
drugs (corticosteroids) corticosteroids to reduce
to suppress the immune inflammnation.
response.
L(D)

Laboratory diagnosis
o Smear microscopy is a diagnostic technique used to visualize acid-fast bacilti in
leprosy lesions.
Specimen Collection:
o Six sawmples are collected: four from the skin (forehead, cheek, chin, buttock), one
from the earlobe, and one from the nasal mucosa.
oA technique called "slit skin smear" is employed to collect skin and earlobe
specimens. The preferred site is the edge of the lesion.
o Biopsy: In some cases, a biopsy from thickened nerves and nodular lesions may be
necessary.
o Appearance:
* M. leprae is less acid-fast compared to tubercle bacilli. Therefore, ziehl-Neelsen
staining is used, with s% sulfuric acid for decolorization.
o Under oil immersion microscopy, red acid-fast bacilli are observed, either singly
or in groups (sometimes forming cigar-like bundles), bound together by a lipid
like substance called glia, which forms globi.
* These globi are present witlhin foamy macrophages known as Virchow's lepra
cells or foamy cells.
o Mouse Foot Pad Cultivation: (footpad of mice or other ninals like nine-banded
armadilos)
* M. leprae cannot be cultivated in artificial culture media or tissue culture,
making it challenging to follow Koch's postulates.

47 RMedEd
< Skin & Soft Tissue Infections

MedEd FARRE: Microbiology

Antibody Detection (FLA-ABS and ELISA):

o FLA-ABS (Fluorescent Leprosy Antibody Absorption Test) is widely used to identify
subclinical cases of leprosy.
o ELISA detects lgM antibodies to the PGL-1 (Phenolic Glycolipid-1) antigen of M.
leprae.
Test for Detecting Cellular Immunity (Lepromin Test):
O At 48 hours (Early or Fernandez Reaction): lnduration (>1o mm) at the inoculation
site indicates a delayed-type hypersensitivity (DTH) reaction to the lepra antigen,
Suggesting past exposure to lepra bacilli.
O At 2 days (Late or Mitsuda Reaction): A nodule of >5 mm size forms at the
inoculation site, which subsequently ulcerates.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. 534

148)
Skin & Soft Tissue Infections

Skin and Soft tissue

63. Write in detail about superficial fungal infections. (10 marks)

Answer:
Superficial Mycoses
o Tinea versicolor, also known as pityriasis versicolor, is a recurrent chronic skin
cOndition affecting the superficial layer (stratum corneum) of the skin. It is caused
by a lipophilic fungus known as Malassezia furfur.
Clinical Manifestations:
o Tinea versicolor presents as flat, round, scaly patches on the skin, with varying
degrees of hypo- to hygperpigmentation
o These lesions are non-inflammatory and usually not itchy, although they can
rarely cause itching.
o Commonly affects areas rich in sebaceous glands, such as the neck, chest, or upper
arms.
o This condition is more prevalent in regions with a humid climate.
Other Manifestations Caused by Malassezia furfur:
o Seborrheic Dermatitis: This condition appears as pruritie, erythematous, and scaly
lesions, often referred to as dandruff in adults or cradle cap in infants.
o Folliculitis
O Atopic dermatitis
LABORATORY DIAGNOSIS
Tinea Versicolor:
O Direct Microscopy: Skin scrapings are treated with 10% KOH and examined
microscopically. This process reveals a mixture of budding yeasts and short septate
hyphae, giving it a distinctive appearance known as the "spaghetti and meatballs
appearance.
o Culture: to the lipophilic nature of Malassezia furfur, culture is performed on
Due
Sabouraud dextrose agar (SDA) with olive oil overlay. After incubating for s-7
days at, characteristic "fried egg" colonies develop.
o Urease Test: A positive urease test can be indicative.
o Wood's Lamp Examination: Under Wood's lamp, scaly lesions exhibit golden yellow
fluorescence.
Treatment for Tinea Versicolor:
o Topical lotions such as selenium sulfide shampoo, ketoconazole shampoo or cream,
and terbinafine cream are typically used fora period of 2 weeks.
Piedra: Piedra is a condition where nodules form on the hair shaft, either black or
white in color.

149) (RMedEd
< Skin & Soft Tissue Infections
MeaLa rAKKE: MICroDioiogy

O White Piedra: White nodules form on the hair shaft., and they are less firmly
attached. This condition is caused by Trichosporon beigeli.
o Black Piedra: Characterized by the formation of firwmly attached black nodules on
the hair shaft. It caused
is by Piedraia hortae.
Dermatophytoses (Ringworm):
O Dermatophytoses, commonly known as ringworm, are superficial fungal infections
affecting the skin, hair, and nails. These infections are caused by a group of fungi
called dermatophytes, including
* Trichophyton: lnfect skin, hair and nail
o Microsporum: lnfect skin and hair
* Epidermophyton: lnfect skin and nails.
o Theclassification of dermatophytes is based on their usual habitat:
3 Anthropophilic: These fungi exclusively infect humans.
* Zoophilic: They infect animals and birds.
* Geophilic: These fungi are commonly found in soil.
Pathogenesis:
O Dermatophyte infections are typically acquired through direct contact with soil,
animals, or humans carrying fungal spores.
o These spores can spread to different areas through scratching. Predisposing factors
include noist, humid skin, and tight, ill-fitting clothing.
Clinical Manifestations:
o ln the skin, dermatophytes cause well-demarcated, annular or ring-shaped,
pruritic, scaly lesions with central clearing and raised edges. Scaling, erythema,
and blister formation may occur.
o ln the nails, they invade through the lateral or superficial nail plates, eading to
brittle nails and areas of alopecia.
o Dermatophytes can invade hair shafts, causing brittleness and alopecia. ln sowme
cases, deep and persistent suppurative foliculitis, known as Majocchi granuloma.

LABORATORY DIAGNOSIS

Wood's Lamp Examination:

o Some dermatophytes exhibit fluorescence when lesions are examined under a
Wood's lamp.
o This test can be positive for various Microsporum species and Trichophyton
schoenleinii.
o The fluorescence is attributed to the presence of pteridine pigment in the fungal
cell walI.

150
Skin & Soft Tissue Infections

Skin and Soft tissue

Specimen Collection:
o For laboratory diagnosis, specimens such as skin scrapings, hair plucks (preferably
broken or scaly ones), and nail clippings are obtained from the active margins of
the lesions. These specimens are kept in folded black paper. It's important to pluck
hair rather than cut it.

Direct Examination:
O The collected specimen is mounted in a solution of KOH (20% for skin scrapings
or hair, 20-407% for nail cippings) or calcofluor white stain.
o It is then examined for the presence of thin septate hyaline hyphae with
arthroconidia.
o ln cases involving hair, the arthroconidia may be found on the surface of the hair
shaft (ectothriw) or within the shat (endothrix).
Culture:
o Specimens are inoculated onto Sabouraud dextrose agar (SDA) containing
cycloheximide and incubated for 4 weeks.
o Microscopic Appearance: Dermatophyte colonies can be teased apart, and LPCB
mounts (Lactophenol cotton blue mounts) are made to examine the hyphae and
spores (conidia). There are two main types of conidia observed: small unicellular
microconidia and large septate macroconidia, both of which are valuable for species
identification.
o Special Hyphae: Dermatophytes typically have thin, septate, and hyaline hyphae.
Hair Perforation Test:
O This test is positive for Trichophyton mentagrophytes and Microsporum canis.
Fungi that can perforate hair willproduce wedge-shaped perforations.
o Urease Test: Trichophyton is urease positive
Molecular Methods:
o Polymerase chin reaction (PCR) can be employed to detect species-specific genes,
such as the chitin synthase gene.i
o Skin Test: This test is used to detect hypersensitivity to dermatophyte antigens,
specifically trichophytin, which can indicate exposure to these fungi.
Treatment
o Oral terbinafine or itraconazole are the preferred drugs.

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, Brd
Edition,, Page No. 574

51 RMedEd
Respiratory Infections

Respiratory
64. Enumerate the common respiratory tract infection along with causative agents.
(3 marks)
Answer.
Lower respiratory tract infections
Bronchitis |Respiratory viruses
Bronchiolitis |Respiratory syncytial virus
Whooping cough (Pertussis) Bordetella pertussis
Lobar pneumonia Pneumococcus, H. influenzae, S. aureus,
K. pneumoniae, and other gram-negative bacilli

Atypical pneumonia | Mycoplasma, Chlamydia, viruses

Pulmonary tuberculosis Mycobacterium tuberculosis
Fungal pneumonia Pneumocystisjirovecii and others
Parasitic lung disease Paragonimus, Ascaris and others
Lung abscess Primary: Anaerobes
|Secondary: Gram-negative bacilli
Pleural effusion and empyema Bacterial (secondary to pneumonia), tubercular
and viral
Upper respiratory tract infections
Pharyngitis and tonsillitis Viral: lnfluenza, coronavirus
Laryngitis Bacterial: S. pyogenes, C. diphtheriae lnfluenza
and parainfluenza viruses
Acute laryngotracheobronchitis Parainfluenza virus
(croup)
Epiglottitis |Haemophilus influenzae b
Peritonsillar abscess (quinsy) S. pyogenes, S. aureus and anaerobes

Ludwig's angina Polymicrobial and anaerobic

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, Brd
Edition, Page No. 587

152)
< Respiratory Infections

Respiratory

65. Enumerate sequelae of streptococcal infection and write in brief about ARF and
PSGN. (3 marks)
Answer:
o
Streptococcal antigens exhibit molecular mimicry with human antigens, leading
to antibodies generated in response to prior streptococcal infections mistakenly
targeting human tissues, which can lead to the development of various
nonsuppurative complications, including:
ARF
PSGN
o Guttate psoriasis
Reactive arthritis
3 PANDAS.
Acute rheumatic fever or ARF
O Acute rheumatic fever (ARF) is a complex, multisystem disease that occurs in
individuals who have previously had a streptococcal (group A) sore throat, typically
as a result of an autoimmune reaction.
Pathogenesis
O Autoimmune theory: This theory is based on molecular mimicry, where antibodies
generated against streptococcal antigens (such as the M protein) cross-react with
human tissue antigens, including those found in the heart and joints. These cross
reactive antibodies can bind to the endothelium of heart valves, uttimately causing
valve damage.
O Cytotoxic theory: This theory suggests that certain toxins and enzymes produced
by streptococci, like streptococcal pyrogenic toxins and streptolysin O, can directly
harm human heart tissues.
Clinical features
o Migratory polyarthritis
O Pancarditis
o Subcutaneous nodules
O Erythema marginatum
o Sydenham chorea
Diagnosis of ARF

It isdiagnosed using revised Jones criteria with supportive evidence of previous Group
A strep infection by using
o Elevated ASO titres
o Positive throat culture

5
RMedEd
< Respiratory Infections

66. Write a short note on non-tuberculous mycobacteria? (S marks)

Answer:
o Nontuberculous nycobacteria (NTM), previously known as atypical mycobacteria
or mycobacteria other than tubercle bacilli (MOT), formn a diverse group of
mycobacteria found in birds, animals, and environmental sources like soil and
water.
o While theyare opportunistic pathogens occasionaly linked to human infections,
there is known person -to-person transmission.
no
o It's important to distinguish saprophytic mycobacteria, which are found in soil,
water, and the environment but do not cause human disease, from NTM.

Runyon Group Characteristics Examples

(Photochromogens) Slow-growing NTM that o Mycobacterium kansasii
produce pigments when Mycobacterium marinum
exposed to light.

I (Scotochromogens) |Slow-growing NTM that|o Mycobacterum

produces pigments in the scrofulaceum
dark.
I (Nonchromogens) Slow-growing NTM o Mycobacterium avium
that do not produce intracellulare complex
Pigments. (MAC)
o Mycobacterium gordonae
IV (Rapid Growers) Rapid-growing NTMO Mycobacterium fortuitum
a
with growth rate of less Mycobacterium abscessus
than 7 days. o Mycobacterium chelonae
Some important mycobacterium:
o M.Marinum: Leads to papules and ulcers known as swimming pool or fish tank
granuloma.
o M.scrofulaceum: Leads to cervical lymphadenitis also known as scrofula.
Mycobacterium avium-intraceltulare complex (MAC):
o Composed of two related organisms: M. avium and M. intracellulare.
o
These bacteria are opportunistic pathogens, particularly affecting individuals with
HIV infection who have a low CD4 T cell count (typicaly less than soluL).
o MAC infections can manifest in various ways, including lymphadenitis (inflammation
of lymph nodes), respiratory infections, and disseminated disease, where the
infection spreads throughout the body.

155) MedE
< Respiratory Infections

MedEd FARRE: Microbiology

Laboratory diagnosis:
o Specimens: Depending on the type of infection, specimens like sputum, lymph
node aspirate, pus or exudate, and skin lesion biopsies may be collected for testing.
o Microscopy by ZN staining: Acid-fast bacilli stained with Zihl-Neelsen (ZN)
staining will appear as red under the microscope. This method helps identify NTM,
but further differentiation from Mycobacterium tuberculosis is necessary.
o Culture on LJ media: Löwenstein -Jensen (Ly) media are commonly used for
culturing NTM. Some NTM species grow better on these media, but growth may
vary between species.
o
Pigment production: LJ media can be incubated in both dark and light conditions
to distinguish between photochromogens (produce pigments only in light) and
scotochrowmogens (produce pigments even in the dark).
o ldentification: NTM species can be differentiated from the M. tuberoulosis complex
through various methods, including:
3 Negative result for MPT64 antigen by immunochromatographic tests (ICT),
suggesting NTM infection rather than M. tuberculosis.
O Newer methods: Modern techniques like MALDI-TOF (matrix -assisted laser
desorption ionization-time of flight) and molecular methods such as PCR are
preferred for species identification of NTM due to their accuracy and efficiency.
Reference: Essentials of Medical Microbiology. Apurba S sastry and sandhya Bhat, Srd
Edition, Page No. S36

{156
Respiratory Infections

67. Write a short note on EBV infection. (5 marks)

Answer:

o Epstein: Barr Virus (EBV) is responsible for infectious mononucleosis and is

associated with various human tumors, including nasopharyngeal carcinoma,
Burkitt's lymphoma, Hodgkin's disease, and B-cell lymphoma.
Morphology of EBV
o EBV belongs to the y sub-family of Herpesviridae. It has double-stranded DNA, is
enveloped, and exhibits icosahedral symmetry.
o EBV Antigens: EBV expresses three classes of antigens:
* Latent phase antigens: These are produced during the latent phase and include
EBV nuclear antigen (EBNA) and latent membrane protein (LMP).
* Early antigens: These are non-structural proteins involved in viral replication.
* Late antigens: These are structural proteins that make up the viral capsid and
envelope.
Pathogenesis
o
EBV spreads through oropharyngeal contact via infected saliva.
o it binds to specific receptors (CD21 or CR2)
for the C3b component of complement.
n B cells, which are also receptors
o EBV replicates in epithelial cells or surface B lymphocytes of the pharynx and
salivary glands.
o Infected B cells become immortalized and produce various immunoglobulins,
including autoantibodies.
o This process triggers atypical CD8 T lymphocytes, a characteristic feature of
infectious mononucleosis. Persistent EBV infection can lead to malignant
transformation of infected B cells and epithelial cells by expressing latent EBV
antigens.
Clinical Manifestations
o Infectious MonOnucleosis: This condition primarily affects young adults and is
characterized by:
* Headache, fever, malaise
o Pharyngitis
* Enlarged cervical lymph nodes
* Hepatosplenomegaly
i Rashes following ampicillin therapy

MedEd
< Respiratory Infections

MedEd FARRE: Microbiology

3 Atypical lymphocytosis (CD8 T cells)

* Autoantibodies reacting to sheep RBC antigens (detected by the Paul-Bunnell
test)
Malignancies:
o Burkitt's Lymphoma
o Nasopharyngeal Carcinoma
o Hodgkin's Lymphoma
o Non-Hodgkin's Lymphoma
Other Conditions Associated with EBV:
o Lymphoproliferative Disorder: This occurs in immunodeficient patients, such as
individuals with Duncan syndrome, an X-linked recessive disease affecting young
boys.
o Oral Hairy Leukoplakia: it presents as wart-like growth on the tongue's epithelial
cells and is observed in some HIV-infected patients and transplant recipients.

LABORATORY DIAGNOSIS
Heterophile Agglutination Test (Paul-Bunnell Test):
o This tube agglutination test uses sheep red blood cells (RBC) to detect heterophile
antibodies in the patient's serum.
O
An agglutination titer of »256 is considered significant. However, false positives
Can ocCur.

EBV-Specific Antibody Detection:

o ELISA
and indirect immunofluorescence techniques are commonly used to detect
specific EBV antibodies.
o Antibodies to viral capsid antigen (VCA): lgM indicates current infection, and lgG
indicates past infection and imnmunity.
o Antibodies to early antigen (EA): lndicate current viral infection, elevated in
certain nalignancies.
o Antibodies to EBNA (Epstein-Barr nuclear antigen): Reveal past infection, but a
four-fold rise may suggest current infection.
o
Detection of EBV DNA (by PCR), or EBV antigens (by direct immunofluorescence
technique) are used in various malignancies and infectious mononucleosis.

158)
Respiratory Infections
MedEd FARRE: Microbiology

68. Write a short note on Pneumocystis jirovecii infection and zygomycosis.

(5 marks)
Answer:
Pathogenesis:
o Pneumocystis exists in two forms, cysts and trophozoites.
o Cysts are found in the environment, while both cysts and trophozoites (containing
sporozoites) are present in human tissues. When inhaled, environmental cysts
reach the lungs and transform into trophozoites.
o Trophozoites induce inflammation, recruiting plasma cells and causing frothy
exudate to fill the alveoli, hence it's also called plasma cell pneumonia.
Clinical manifestations:
o
Fever: Patients with PCP typically have a high fever.
o
Cough: A dry, nonproductive cough is common and may progress to a more severe
cough with the production of sputum as the infection worsens.
o Shortness of Breath: Breathlessness and difficulty in breathing, especially during
physical activity, are hallmark symptoms.
o Chest Pain: Some individuals may experience chest pain,often due to inflammation
and damage to lung tissue.
O Weight Loss: Unexplained weight loss is a common symptom.
O Night Sweats: Profuse sweating during the night can occur.
Laboratory Diagnosis:
O Histopathology: Examination of lung tissue or fluids obtained through procedures
like bronchoscopy, bronchoalveolar lavage (BAL), or open lung biopsy reveals cysts.
Gomori's methenamine silver (aMS) staining is preferred, showing cysts resembling
black erushed ping-pong balls against a green background.
o PCR ASsay: Developed for detecting specific genes of P.jirovecii.
o 1, 3 B-D-Glucan: Serum test for detection.
o Radiology: ChestX-ray and CT scans may show bilateral diffuse infiltrates. Ground
glass opacities can be seen at carly stages, but atypical manifestations like nodular
densities and cavitary lesions are also reported.
Treatment:
O Cotrimoxazole is the DOC
Zygomycosis:
o Zygomycosis is a group. of severe infections caused by aseptate fungi in the
Zygomycota phylum.

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< Respiratory Infections
Respiratory
o Rhizopus (R. arrhizus and R. microsporus)
O Mucor racemosuS
Mucormycosis Pathogenesis:
o Spores of these fungi are common in the environment.
o Transmission occurs via inhalation, inoculation, or rarely ingestion of spores.
o Spores develop into mycelial forms with wide aseptate hyphae, which are
angioinvasive, leading to the spread of infection.
Predisposing factors for Mucormycosis:
o Conditions with increased iron load (require iron as a growth factor), such as
diabetic ketoacidosis (DKA).
o End-stage renal disease.
o Patients taking iron therapy or deferoxamine (an iron chelator).
o Defects in phagocytic functions
Clinical Manifestations of Mucormycosis:It can have various clinical presentations,
including
O Rhinocerebral: Facial pain, orbital cellulitis and vision loss occurs.
o Pulmonary: Dyspnea, cough, chest pain.
O Cutaneous form
o Gastrointestinal form
o Dissewminated form
Laboratory Diagnosis:
o Histopathological staining of tissue biopsies shows broad aseptate hyaline hyphae
with wide -angle branching.
o Culture on SDA at 25°C reveals characteristic white, cottony, woolly colonies with
tube -filling growth (referred to as "lid lifters").
o Microscopic examination of colonies shows broad aseptate hyaline hyphae.
o Rhizoids: Unique root-like growth arising from the hyphae of certain species of
fungi known as rhizoids.
* Rhizopus: nodal rhizoids
Mucor: bsent rhizoids.
Treatment:
O Amphotericin Bis the DOC

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 679
D00

MedEd
161
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Respiratory Infections

MedEd FARRE: Microbiology

69. Draw the structure of the influenza virus and explain the mechanism of generation
of epidemic strains. (5 marks)
Answer:
MORPHOLOGY

M2

NA

M1

HA

Negative sense
ssRNA (8
segments)

o Helical Symmetry: These viruses have a helical nucleocapsid structure surrounded

by an envelope.
o Viral RNA: The viral RNA is segmented, meaning it consists of multiple segments
of negative -sense, single-stranded RNA. Each RNA segment codes for a specific
viral protein with a unique function. Influenza A and B have eight RNA Segments,
while Influenza C and D have seven segments, lacking the segment coding for
neuraminidase.
o Site of Replication: The virus replicates its RNA in the nucleus of host cells.
o Viral Proteins: lnfluenza viruses contain eight structural proteins (PB1, PB2, PA,
NP, HA, NA, M1, and M2) and two non-structural proteins (NS1 and NS2).
o The polymerase proteins PB1, PB2, and PA are responsible for RNA transcription
and replication.
o NP, the nucleoprotein, is a major capsid protein that binds to viral RNA to form
ribonucleoprotein or nucleocapsid with helical symmetry.
O Matrix Proteins:
o M1 Protein: This isa major viral protein that forms a protective shell or protein
layer underneath the viral envelope.
< Respiratory Infections
Respiratoy
M2 Protein: These proteins function as ion channels in the viral envelope, aiding
in the transport of molecules.
O Non-Structural Proteins:
* NS1: This protein acts as an interferon antagonist, inhibiting the host cell's
interferon response. It also plays a role in preventing pre-mRNA splicing.
* NS2: NS2 helps in exporting molecules across the nucleus of the host cell.
o Envelope:
* Hemagglutinin (HA); HA is responsible for binding to mucin or sialic acid receptors
On the respiratory epithelial cells. This binding facilitates the entry of the virus
into host cells.
* Neuraminidase (NA): It functions as a sialidase enzyme, breaking down sialic acid
receptors on host cells. This action helps release virus particles from infected cell
surfaces during the budding process and prevents the self-aggregation of virions
to host cells. NA also aids the virus in passing through the mucin layer in the
respiratory tract to reach target epithelial cells.
MECHANISM OF ANTIGENIC VARIATION IN INFLUENZA VIRUS

Antigenic Drift:
o Antigenic drift is a minor change in the virus's surface proteins, specifically the HA
(hemagglutinin) and NA (neuraminidase) genes.
o It is caused by point mutations, resulting in small alterations in the amino acid
sequence of the antigenic sites on HA and NA.
o These minor changes allow the virus to partially evade recognition by the host's
immune system.
o To become epidemiologically significant, a new variant typically needs to sustain
two or more mutations.
o Antigenic drift is observed in both influenza virus types A and B.
o It leads to the occurrence of outbreaks and minor periodic epidemics.
o Antigenic drift is relatively frequent, happening approximately every 2 to 3 years.
Antigenic Shift:
o Antigenic shift represents a major, abrupt, and drastic change in the sequence of
a viral surface protein, particularly HA and NA.
o It occurs due to qenetic reassortment between the genomes of two or more
influenza viruses that infect the same host cells.

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o This genetic reassortment results in the emergence of a completely new

virus
strain that antigenically unrelated to the predecessor strains.
is
o Antibodies developed against previous strains, whether through infection or
vaccination, are often ineffective against the new strain.
o Antigenic shift a siqnificant event that can lead to the emerqence of novel
influenza strains with pandemic potential.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat,
3rd
Edition, Page No. 679

ViedEo

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Respiratory

70. Write a short note on Pseudomonas infection. (S marks)

Answer:
O Pseudomonas infections are caused by a group of gram-negative bacteria known
for their ability to resist multiple antibiotics and disinfectants.
Pathogenesis and virulence
o Colonization: The infection starts with the bacteria adhering to and colonizing the
host's surfaces. Factors like pili, fimbriae, and polar lagela aid in adhesion and
movemnent towards the host.
o Toxin-Mediated Immune Evasion and Tissue Injury: Pseudomonas aeruginosa, in
particular, produces numerous toxins and enzymes. These can be categorized into
nondiffusible toxins, which are injected into host cells, allowing the bacteria to
evade phagocytic cells and cause tissue damage. Diffusible toxins act freely and can
damage tissues. Exotoxin A is a critical virulence factor, inhibiting protein synthesis
o Pigment Production: Pseudomonas produces various pigments that can inhibit
other bacteria and contribute to tissue injury. Examples include pyocyanin (blue
green pigment), fluorescein (greenish-yellow), pyorubin (red), and pyomelanin
(brown-black).
O Alginate Coat: Some strains of Pseudomonas develop a slime layer or alginate coat,
aiding in biofilm formation, adherence to host cells, and mucus production, often
causing infections in individuals with cystic fibrosis.
o Capsule: Many Pseudomonas strains have a protective polysaccharide capsule that
helps them avoid phagocytosis by immune cells.
o
Multidrug Resistance
o Biofilm Formation
O Wide Temperature Range
Clinical Manifestations:
o Healthcare-associated infections like ventilator-associated pneumonia (VAP),
bloodstream infections, urinary tract infections, and surgical site infections, burns.
o Chronic respiratory tract infections in individuals with conditions like cystic fibrosis.
o
Bacteremia leads to sepsis and septic shock.
O lnfections in various body parts such as the ears, eyes, and skin.
o Bone and joint infections, meningitis, and more.
Laboratory diagnosis:
o Specimen Collection: Specimens such as pus, wound swabs, urine, sputum, blood,
or cerebrospinal fluid (CSF) are collected based on the suspected site of infection.
o Direct Smear: Gram staining of the specimen is perforwmed, which typically shows
numerous pus cells and slender gram -negative bacilli.

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Culture:
o Peptone Water: Pseudomonas forms uniform turbidity with a surface pelicle
to
formation due higher oxygen tension at the surface.
O
Nutrient Agar: It results in the formation of large, opaque, irregular colonies with
a metallic sheen, described as iridescence.
o Pigments: Most strains of Pseudomonas produce diffusible pigments, which can be
blue-green (pyocyanin) or yellow-green (pyoverdin). Some strains may be non
pigmented. Colonies often have a sweet, ether-like or fruity odor.
O Blood Agar: On blood agar, Pseudomonas produces p-hemolytic gray moist colonies.
o MacConkey Agar: Pseudomonas colonies on MacConkey agar appear pale and are
non-lactose fermenting.
o Selective Media: Cetrimide agar is an example of selective media used to isolate
Pseudomonas frowm mixed growth in purulent specimens.
o
Culture Smear and Motility: Microscopic examination of cultured Pseudomonas
typically shows gram-negative bacilli. These bacteria are actively motile,
characterized by a single polar flagellum, which can be observed using a hanging
drop test
ldentification:
O
Oxidase and catalase positive
o lndole -ve
o Catalase +ve

o Urease -ve
o TSI- alkaline/alkaline with no gas and no H,s.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, srd
Edition, Page No. 642

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< Respiratory Infections
71. A 23-year-old male presents to the OPD with complaints of swelling in the neck
along with cough with expectoration. He also gives a history of evening rise in
body temperature and weight loss.
(A) What is the diagnosis? (10 marks)
(B) Write it's pathogenesis and clinical manifestations
(C) Write the laboratory diagnosis
Answer:
(A) The most probable diagnosis is tuberculosis. The causes of tuberculosis are
O M.tuberculosis
O M.bovis

o Less commonly caused by M.caprae, M.africanum etc.

(B) Virulence and Pathogenesis
o Cell Wall (Insoluble) Antigens: The cell wall of M. tuberculosis is composed of several
layers, including:
* Peptidoglycan Layer: This layer maintains the shape and rigidity of the bacterial
cell.

* Arabinogalactan Layer: lt is a major structural component of the mycobacterial

cell wall.
o Mycolic Acid Layer: This layer is the principal constituent, consisting of long-chain
fatty acids attached to arabinogalactan. It contributes to the impermeability of
the cell wall, making the bacteriuwm acid-fast and resistant to many antibiotics.
Source of Infection:
o Human Source: PulmOnary tuberculosis cases in humans are a siqnificant source
of infection.
o Bovine Source: Consumption of unpasteurized infected milk can be another source
of infection.
Mode of Transmission:
o Airborne
Risk Factors for Transmission:
o Sputum Positivity: Patients with positive sputum, indicating the presence of acid
fast tubercle bacilli, are more efficient at transmitting the disease.
o Bacillary Load: Higher bacillary load in sputum, especially in patients with cavitary
lung lesions, increases transmission risk.
o Overerowding: Poorly ventilated, overcrowded rooms facilitate transmission.

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Endogenous Risk Factors for Disease Development:

o Low Cell: Mediated lmMmunity
O Comorbid Conditions: Various comorbid conditions like renal transplant, diabetes,
Smoking, and more can increase the risk of progression to active disease.
O
Age and Sex: Young adults and the elderly have an increased risk.
Sequence of Pathogenic Events:
o Inhalation: Droplet nuclei containing tubercle bacilli from infected individuals are
inhaled, with only a fraction reaching the alveoli.
o
Adhesion to Macrophages: Surface molecules like lipoarabinomannan (LAM) on
mycobacteria bind to complement and mannose receptors on macrophages.
o Phagocytosis: Macrophages engulf the bacilli, a process enhanced by conmplement
mediated opsonization.
o Survival Inside Macrophages: Mycobacterial cell wall components, particularly
LAM, impair phagolysosome fusion, allowing the bacilli to survive and replicate
inside wmacrophages.
o
Rupture of Macrophages: Eventually, infected macrophages rupture, releasing
bacillary contents to infect other phagocytes, perpetuating the infection cycle.
Divides-controlabally inside
macrophage
Mycobacteria tuberculosis Langhan giant cell

Epitheloid cell

Macrophage

T-els

Caseous necrosis
Releasing IFN-y

Phagolysosome maturation and

Granuloma formation
T cell binds and activates macrophages activation
Production of nitric oxide
•Productlon of reactive oxygen
species
Autophagy

CLINICAL MANIFESTATIONS

Pulmonary Tuberculosis (PTB):

o PTB is the most common form of TB, accounting for 60-40% of all TB cases.
o it can be categorized as primary or postprimary (secondary) TB.

68
< Respiratory Infections
Respiratory
o Primary PTB occurs when a person is initially exposed to M. tuberculosis and
typically affects the upper lobes of the lungs.
o Postprimary PTB, also known as secondary TB, is a eactivation of latent infection
and usually affects the lower lobes of the lungs.
o Symptoms of PTB can include a chronic cough, fever, night sweats, weight loss,
and hemoptysis (coughing up blood).
Extrapulwmonary Tuberculosis (EPTB):
o Common sites for EPTB involvement include:
* Tuberculous lymphadenitis (swelling in the neck region)
* Pleural tuberculosis (pleural effusion)
* Tuberculosis of the upper airways (larynx, pharynx, epiglottis)
Skeletal tuberculosis (spine, hips, knees)
* Tubereulosis of the central nervous system (meningitis, tuberculoma)
• Tuberculous skin lesions (scrofuloderma, lupus vulgaris)
LABORATORY DIAGNOSIS
Specimen Collection for Pulmonary Tuberculosis (PTs):
o For PTB, two sputum samples are typically recommended: a spot sample collected
on the same day (under supervision) and an early morning sample collected on
the next day.
o Alternatively, two spot samples taken at least one hour apart can be collected.
Early morning sputum should be collected on an empty stomach after rinsing the
O

mouth to remove food remnants.

O Patients should be instructed to inhale deeply and cough from the chest to produce
good-quality sputum.
Specimen Collection for Extrapulmonary Tuberculosis (EPTB):
o The collection of extrapulmonary specimens varies depending on the site involved,
such as lymph nodes, pleura, CSF, etc.
o Different types of specimens may be collected, including aspirates, biopsies, or
fluids.
Digestion, Decontamination, and Concentration:
o Sputum and specimens from non-sterile sites need prior treatment for digestion,
decontamination, and concentration.
o
Modified Petroff's method-The most common method involves using 4% sodium
hydroxide (NaOH) to liquefy the sputum, inhibit nornal flora, and increase the
yield.

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Direct Microscopy by Acid-fast Staining (Ziehl-Neelsen Technique):

O The Smear
i stained using acid-fast stains (ZN stain) and examined under a
microscope.
O A positive result shows Mycobacterium tuberculosis as long, slender, beaded, less
uniformly stained red-colored acid-fast bacilli (AFB).
o MicroScopy provides a presumptive diagnosis, and if a typical AFB appearance is
seen, it is reported as resembling M. tuberculosis.
o Advantages: Rapid, easy, and cost-effective.
o Disadvantages: Lower sensitivity
Kinyoun's Cold Acid-fast Staining:
O Differs from ZN stain as it doesn't require heating, uses increased phenol
cOncentration in carbol fuchsin, and has a longer duration of carbol fuchsin staining.
Fluorescence Staining:
o Uses an auramine-phenol solution for staining.
O More sensitive than ZN staining, recommended by RNTCP.
o The bacilli appear brilliant yellow against a dark background.
Culture Methods:
o Considered the gold standard for TB diagnosis.
o More sensitive than microscopy.
o Detects viable bacilli.
o Allows for drug susceptibility testing.
o Multiple culture media such as
Lowenstein-Jensen (LJ) medium

o MPTo4 antigen is detected in culture to confirm TB.

Molecular test
o PCR: used to detect iS6110, MPT64 and other genes to identify TB bacilli.
o GeneXpert (CBNAAT): Rapid test with high senitivity and specificity and also
detects rifampicin resistance.
o Line probe assay: This is used to detect various drug sensitivities of the tubercular
bacilli to aid in treatment.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. 623
O00

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72. A SO-year-old female arrived at the emergency room with a persistent dry
cough, high fever (101.8°F or 38.g °C), and increasing difficulty breathing. She
reported fatigue and body aches for the past four days. Physical examination
showed mild tachypnea (rapid breathing) and decreased oxygen saturation (92%)
On roomn air. Lung auscultation revealed bilateral crackles in
the lower lung fields.
(A) What is the probable diagnosis? (10 marks)
(B) Write its Pathogenesis and clinical manifestations.
(C) Write its laboratory diagnosis.
Answer:

The most probable diagnosis is Covid-19 infection.

Morpholog9
o
itis an enveloped virus with club-shaped proteins attached all around the periphery
of the virus giving it a crown-shaped appearance in electron microscopy.
l(B) PATHOGENESIS
Transmission:
Droplet Transmission: COVID-19 primarily spreads through respiratory droplets
when an infected person coughs, sneezes or has close personal contact with others
within 1 meter.
o Contact Transmision: The virus can be transmitted directly by contact with infected
individuals or indirectly through contact with contaminated surfaces, objects, or
fomites. After contact, the virus can be transmitted to mucous membranes by
touching the face, mouth, ose, or eyes.
o Aerosol Transmission: While not well-documented, aerosol transmission (spread
of droplet nuclei beyond one meter) may occur, particularly during aerosol
generating procedures like endotracheal intubation.
Host Cell Entry:
o SARS-CoV-2 enters host cells by binding its spike glycoprotein (S) to the host cell
receptor ACE-2.
o This receptor is highly expressed in various tissues, including the tungs, heart,
kidney, and intestine. The virus infects pharyngeal epithelium, leading to influenza
like illness (IL) at the early stage.
Development of ILI(Influenza-Like Illness):
o COVID-19 often begins with symptoms similar to influenza (IL) due to infection
of the pharyngeal epithelium. These symptoms include fever, cough, sore throat,
and fatigue.

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Development of ARDS (Acute Respiratory Distress Syndrome):
o The leading cause of mortality in COVID-19 patients is hypoxemic respiratory
failure, which can progress to acute respiratory distress syndrome (ARDS).
o Factors contributing to ARDS include:
Reduced production of pulmonary surfactants due to damage to type-tl alveolar
cells.
* Hyperactive muscular movement of inspiration leads to inereased lung volume.
* Cytokine stormwith uncontrolled immuneresponse and elevatedproinflammatory
cytokines.
Dilatation of blood vessels, allowing fluid passage and causing pulmonary edema.
* Fibrosis and recruitment of fibroblasts in later stages lead to respiratory failure.
o Multiorgan faiture due to cytokine-induced damage to other organs.
Typlcal Vrvs SARS-CoV-2

ACE2

Immunopathology
IFN
Immune
Vral Homeostasis Impaired DAMP
Clearance IFN
Cytokine
DAMP 1 Storm
ytoklne Reglatoy
Chemoknes ue Cls
ADE?
Pathogenie
Tcells?

Other
Receptors?
,Myelokd Cells
Lymphopenla Myelold Cell
.g. IFN-Y Hyper-activatlon
B Cells r Cells
Clinical Manifestations:
o COVID-19 patients may present with various symptoms, including
* Fever, cough, fatigue, shortness of breath, myalgia, rhinorrhea, sore throat,
diarrhea, and loss of smell or taste sensation.
* Atypical symptoms may occur in older. or immune-suppressed individuals,
including reduced alertness and mobility, delirium, and absence of fever.
o Risk factors for severe disease include age over 6o years and underlying comorbidities
2

such as diabetes, hypertension, cardiac disease.

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Laboratory diagnosis of COVID-19 involves several methods and considerations:
Specimen Collection and Transport:
o Preferred specimens include throat and nasal swabs,
collected with appropriate
personal protective equipment (PPE).
o
Specimens should be properly labeled, packed, and transported while
maintaining
the cold chain.
Nucleic Acid Amplification Testing (NAAT):
o Real-time RT-PCR is the gold standard for CovID-19 diagnosis.
o It targets specific genes, including screening genes (e.g., spike
protein, envelope
protein) and confirmatory genes (e.g., RNA-dependent RNA polymerase, open
reading frames).
O A
sample is considered positive when both screening and confirmatory genes are
detected with a CT value s 40 cycles.
O NAAT detects the virus as earty as day 1 of symptom onset,
peaks around day s,
and starts to decline by the 3rd week.
Automated Real-time RT-PCR:
O Automated platforms like Truenat and CBNAAT are
available and have a quick
turnaround timne (30-60 minutes).
Antigen Detection:
o Rapid antigen tests are available for quatitative detection of specific antigens
(nucleocapsid protein) to SARS-Cov-2.
o
They are point-of-care tests and provide results within an hour.
Antibody Detection:
O
lgG antibodies appear about two weeks ater infection and can persist.
o Antibody tests (ELISA, chemiluminescence, immunochromatographic) are used for
sero-surveillance purposes
Prognostic Markers:
o Several markers like elevated IL-6 levels, D-dimer, serum ferritin, lymphopenia,
and C-reactive protein can help aSsess disease severity. particularly in the context
of ARDS.
o CT scans of the lungs may show characteristic ground-glass appearance and/or
consolidation.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. G60

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73. A 6-year-old male presents with sore throat and difficulty swallowing parents
mentioned that he has not been vaccinated according to the recommended
schedule. He hada mild fever and a sore throat for the past two days. His parents
noticed a grayish-white membrane in the back of his throat. His neck was swollen
(bull neck appearance). (10 marks)
(A) What is the diagnosis?
(B) What are the Pathogenesis and clinical manifestations of the infection agent?
(C) Write it's laboratory diagnosis

(D) Write in brief about its vaccine

Answer:
(A) The probable diagnosis is Faucial diphtheria due to Corynebacterium diphtheriae.
(B) Virulence factors
Diphtheria Toxin (D):
o Diphtheria toxin is a polypeptide chain consisting of two fragments, A (active) and
B (binding).
o Fragment B binds to host cell receptors (e.g., epidermal growth factor), facilitating
the entry of fragment A into the host cell.
O Fragment A is the active component responsible for the toxic effects.
Mechanism of Diphtheria Toxin:
o Fragment A of diphtheria toxin inhibits protein synthesis in host cells. It does this
by ADP ribosylating elongation factor 2 (EF-2), which leads to the inhibition of
EF-2 and, subsequently, the translation step of protein synthesis.
Factors Regulating Toxin Production:
o The tox gene is carried by a bacteriophage calledB-corynephage, and C. diphtheriae
remains toxigenic as long as these phages are present (lysogenic conversion).
Pathogenicity and Clinical Manifestations:
o Diphtheria is a toxe mia, primarily wmediated by the toxin, not bacteremia.
o The bacterium remains noninvasive and is localized at the primary site (e.g.
pharyn), while the toxin spreads through the bloodstream to various organs.
Respiratory Diphtheria:
o This is the most common form of diphtheria, affecting the tonsils, pharynx (faucial
diphtheria), nose, and larynx.
o
The incubation period is approximately 3-4 days.
o Faucial diphtheria results in an inflammatory response, leading to necrosis of the
epithelium and exudate formation.

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o A leathery grayish-white pseudomembrane forms on the mucoSa, composed of

fibrin, neutrophils, RBCS, and bacteria.
o It is adherent to the mucosal base and bleeds upon removal.
1.Extension of Pseudomembrane: ln severe cases, the pseudomembrane
characteristic of diphtheria may extend into the larynx and bronchial airways.
potentially leading to fatal airway obstruction, which can result in asphyxia.
lmmediate tracheostomy may be necessary in such cases.
2.Bull-Neck Appearance: Patients with severe diphtheria may develop a "bul
neck" appearance, characterized by massive tonsillar swelling and neck edema.
This can lead to symptoms like foul breath, thick speech, and stridor (noisy
breathing).
Cutaneous Diphtheria:
o
Cutaneous diphtheria presents as punched-out lcerative lesions with necrosis, or
rarely. pseudomembrane forwmation. These lesions are most commonly found on
the extemities.
Systemic Complications:
O Diphthera can lead to various systemic complications,including:

* Polyneuropathy
* Myocarditis (associated with arrhythmias and dilated cardiomyopathy)
Pneumonia, Pulmonary embolism
Renal failure

* Encephalitis, Cerebral infarction

LABORATORY DIAGNOSIS
(solation of Diphtheria Bacill:
o Useful specimens include throat swabs (with fibrinous exudates), portions of
pseudomembrane, or, in sOme cases, nose or skin specimens.
o Gram staining reveals irregularly stained club-shaped gram-positive bacilli
arranged in characteristic patterns.
o Albert's stain, wmore specific for C. diphtheriae, shows green bacilli with bluish
black metachromatic granules at the poles.
Culture:
o It is fastidious and requires enriched media like blood agar, chocolate agar, and
Loeffler's serumslope for growth. y

o
Selective media fike potassium tellurite agar (PTA) can be used which show black
colonies.

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Toxin Demonstration:
o In vivo tests involve inoculating culture broth into guinea pigs, although this method
israrely used today.
vitro tests include Elek's gel precipitation test, which is an immunodiffusion test
o In

that can detect the presence of diphtheria toxin

PREVENTION
Types of Diphtheria Vaccines:
o Single Vaccine: Diphtheria toxoid (D) is a single vaccine. It is prepared by incubating
diphtheria toxin with formalin to inactivate it.
o Combined Vaccines:
* DPT: This vaccine combines DT (diphtheria toxoid), whole-cell Pertussis (P), and
TT (tetanus toxoid).
* DaPT: It includes DT, TT, and acellular Pertussis (aP).
* Td: Td contains tetanus toxoid and an adult dose of diphtheria toxoid.
o Pentavalent Vaccine: DPT can also be administered along with hepatitis B and
Haemophilus influenzae type b (Hib) vaccines, creating a pentavalent combination.
Diphtheria Vaccine Administration Schedule:
o Under the National lmmunization Schedule (NIS) of lndia 2020:
Children receive a total of seven doses, including three doses of the pentavalent
vaccine at 6, 1O, and 14 weeks after birth.
Booster doses of DPT are given at 26-24 months and 5 years, followed by
booster doses of Td at 1O years and 16 years.
o Pregnant women should also receive two doses of Td at a one-month interval.
Adverse Reactions Following DPT Administration:
o Mild: Common adverse reactions include fever and local reactions such as swelling
and induration at the injection site.
o Severe: Whole-cell killed Pertussis vaccine can be associated with neurological
complications, especially in children over 7 years of age.
Absolute Contraindications to DPT Include:
o Hypersensitivity to a previous dose of the vaccine.
o Progressive neurological disorders.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. 599

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74. Explain Atypical pneumonia in detail. (10 marks)

Answer:
O Atypical pneumonia, also known as interstitial pneumonia, occurs when an
infection affects the interstitial space of the tungs.
o Unlike typical pneumonia, cough in atypical pneumonia is characteristically non
productive.
o
Comnon causative agents include:
* Respiratory Viruses: This category includes influenza viruses, coronaviruses, RSV,
EBV, adenoviruses, and others.
o Bacterial Agents: Mycoplasma pneumoniae
* Chlamydiae: Includes Chiamydophila pneumoníae.
* Legionella Species
* Less Common Bacterial Agents: Coxiella burnetii, Francisella tularensis, and
Orientia tsutsugaushi.

Mycoplasma pneumoniae Legionella

Pathogenesis Attachment: It is mediated by ltisreach the lungs and

membrane-bound adhesion engulfed by alveolar
proteins, the cytadhesin P1 macrophages.
protein. They can evade destruction
Respiratory Tissue Injury: Once within these macrophages and
attached, it induces injury to inhibit phagosome-lysosome
the host respiratory tissue. fusion, allowing them to
multiply intracellularly.
Clinical Upper Respiratory Tract| Pontiac Fever: It is an acute, flu
Manifestations Infections (URTI): These can like illness with symptoms like
manifest as pharyngitis, malaise, fever, and headache.
tracheobronchitis, or, rarely,It is self-limiting and does not
otitis media. |progress to pneumonia.
Pneumonia: often referred Legionnaires' Disease
to as "walking pneumonia." (Pneumonia): This form of
Symptonms tend to be milder infection is characterized
than Typical features including by interstitial atypical
wheezing or rales, a dry cough, pneumonia with symptoms
and peribronchial pneumonia |Such as non-productive
visible on chest X-rays. While cough, dyspnea, chest pain,
|pneumonia is generally mild |high fever, and sometimes
and self-limited, it can diarrhea. Chest X-rays
progress to ARDs. typically show pulmonary
infiltrates.

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Extrapulmonary CNS conditions Common extrapulmonary stes

|Manifestations (meningoencephalitis, include the heart (resulting in
encephalitis, GBS and aseptic conditions like myocarditis,
meningitis) pericarditis, and prosthetic
valve endocarditis), as well
Dermatological issues as other sites like the sinuses,
(erythema multiforme major
or SJS) peritoneum, kidneys, skin, and
soft tissues.
Cardiac problems (myocarditis,
pericarditis)
Reactive arthritis
Haematological
complications (anaemia and
|hypercoagulopathy).
Mycoplasma pneumoniae
o Small Size: Mycoplasmas are among the smallest microorganisms capable of free
living in the environment. They can be filtered by bacterial filters.
O
Resemblance to Viruses: In some aspects, they resemble viruses. However, they
differ in critical ways:
* They can exist independently in the environment.
They can grow on artificial cell-free culture media.
O
Lack of Rigid Cell Wall: Mycoplasmas lack a rigid cell wall, which is replaced
by a triple-layered cell membrane containing sterols. This makes them entirely
resistant to antibiotics that target the cell wall, such as B-lactams.
O Pleomorphic: Mycoplasmas exhibit high pleomorphism.
Laboratory Diagnosis of Mycoplasma pneumoniae:
o Specimen Collection and Transport: ldeal specimens for testing include throat
swabs, nasopharyngeal aspirates, bronchial brushing, bronchoalveolar lavages
(BAL), and lung biopsies.
o Culture: It is cultured on PPLO agar, colonies have a "fried egg appearance.
o Antigenic Detection: Several. antigenic detection methods are available:
* Direct lmmunofluorescence Test
* Capture ELISA Assay
o Antibody Detection in Serunm: Antibodies specific to M.
pneumoniae protein and
glycolipid antigens can be detected in serum, These include:
Immunofluorescence assays
$ Latex agglutination assays
» ELISA using protein P1 antigens

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< Respiratory Infections

Respiratory
o Molecular Methods: Real-time PCR and BioFire FilmArray Respiratory panel.
LEGIONNAIRES DISEASE

Transmission
o Legionella infections can occur through aspiration of contaminated water, inhalation
of aerosols from SOurces like air conditioners, nebulizers, and direct instillation into
the lungs during respiratory tract procedures.
O Human-to-human transmission does not occur.
Laboratory Diagnosis of Legionellosis:
o Direct Microscopy:
Gram Stain: Legionellae are poorly stained by Gram stain and can be missed or
appear as faint, pleowmorphic, gram-negative rods or coccobacilli.
* Other stains Silver lmpregnation, Giemsa Stains, direct lmmunofluorescence,
Acid-Fast Staining
o Culture: Using Buffered Charcoal, Yeast Extract (BCYE) Agar: Legionellae are
fastidious and grow on this complex medium. It takes 3-5 days of incubation at
37°C in S% CO2 to see growth.
o ldentification: Species identification of Legionella from colonies can be done through:
* Conventional Biochemical Tests.
* Automated ldentification Systems, such as MALDI-TOF.
O
Antibody Detection:
Serology: lndirect lmmunofiuorescent Antibody Test and Enzyme lmmunoassays.
o Cross-reactivity can occur with other Legionella species.
o Urinary Antigen Test: Importantly, prior antibiotic administration does not affect
this test.
o Molecular Methods:
BioFire FilmArray: This s an automated multiplex PCR test.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 618

179) (RMedEd
< Respiratory Infections
MedEd FARRE: Microbiology

75. A 60-year-old male with complaints of a persistent cough, fever (101°F or

38.3°C), and increasing shortness of breath. He mentioned occasional chest pain
and coughing up blood-tinged sputum. He lives in an old, moldy house. Physical
examination revealed diminished breath sounds on the ight side of his chest.A
chest X-ray showed a cavitary lesion in the right upper lobe of the lung. Blood
tests indicated an elevated white blood cell count.
(10 marks)
(A) What is the probable diagnosis
(B) What are the Pathogenesis and clinical manifestation of this organism
(C) Write it's laboratory diagnosis
Answer:
ASPERGILLOSIS
Pathogenesis:
O Aspergillosis is caused by hyaline mold named Aspergillus, with
important species
being A. fumigatus, A. flavus, and A. niger.
Transmission occurs through the inhalation of airborne conidia.
O Risk factors for invasive aspergillosis include glucocorticoid use, neutropenia,
neutrophil dysfunction, underlying lung diseases (e.g. COPD, tuberculosis), and
anti-tumor necrosis factor therapy.
Clinical Manifestations:
o Depending on the site of involvement, Aspergillus can lead to various clinical
manifestations:
O Pulmonary aspergillosis (most common form):
* Allergic bronchopulmonary aspergillosis (ABPA)
* Severe bronchial asthma
o Extrinsic allergic alveolitis
* Aspergilloma (fungal bal)
* Acute angioinvasive pulmonary aspergillosis
* Chronic cavitary pulmonary aspergillosis.
O Other forms:
* Invasive sinusitis
Cardiac aspergillosis (endocarditis and pericarditis)
• Cerebral aspergillosis (brain abscess, hemorrhagic infarction, meningitis)
4 Ocular aspergillosis (keratitis and endophthalmitis)

180
<Respiratory Infections

* Cutaneous aspergillosis
* Nail bed infection (onychomycosis)
* Mycotoxicosis (e.g., aflatoxin-producing A. flavus).
Laboratory Diagnosis:
o Specimens collected can include sputum and tissue biopsies.
o Direct Examination: KOH mount or histopathological staining reveals narrow
septate hyaline hyphae with acute angle branching.
o Culture: Inoculate specimens onto Sabouraud dextrose agar (SDA) and incubate at
25°C. Species identification is based on colony appearance.
O
Antigen Detection:
* B-d-alucan Antigen Assay: A marker of invasive fungal infections.
» Galactomannan Antigen: Aspergillus-specific antigen detected by ELISA in
patient's sera or urine. Useful for earty diagnosis.
o Antibody Detection: Serum antibody detection is useful for chronic invasive
aspergillosis and aspergilloma.
o Skin Test: Positive skin test to Aspergillus antigen extracts indicates hypersensitivity
response and is typically seen in various allergic forms of aspergillosis.

Macroscopic appearance Microscopie appearance of

Aspergillus species colony (LPCB mount)
of colony
|A. fumigatus Colonies-smoky green, Vesicle is conical-shaped
velvety to powdery Phialides are arranged
reverse in
is white row
single
Conidia arise from upper
third of vesicle Conidia are
hyaline.
A. flavus Colonies-yellow green, esicle is globular-shaped
velvety, reverse is white Phialides in one or tWo rowS.
Conidia arise rom upper
two-third to entire vesicle
Conidia are hyaline.
A. niger Colonies-black, cottony Vesicle is globular-shaped
type, everse is white Phialides in two ows Conidia
arise from entire vesicle.
Conidia are black in color

MedEd
181
CNS Infections

CNS
76. What are the infective syndromes of the Central nervous system and the agents
causing it? (3 marks)
Answer:
Routes of infection are:
o Hematogenous: enters subarachnoid space via choroid plexus
O Direct spread: from adjacent sites like otitis media.
O Anatomical defect: like in surgery or trauma

o Direct neural spread: In HSV and Rabies virus. These spread along the nerve

Infective Syndrome of CNS

Meningitis Encephalitis SOL Other lnfection AES

Suppurative
Focal Brain thrombophlebitis
abscess

Subdural & Infectious myelitis

Epidural empyema

Cystic Parasitic
disease Toxin Mediated
o
Meningitis: It is the inflammation of the leptomeninges of the brain with the
involvement of subarachnoid space. Various pathogens lead to meningitis.
o Encephalitis: Acute inflammation of brain parenchyma by infectious agents.
Virus: Rabies, herpes, Japanese encephalitis
* Parasitic agents: Toxoplasma gondi and Naegleria fowleri.
O Brain abscess: Localised collection of pus within the cavity of the brain as a result
of the breakdown of tissue due to infection. The causative agents are
s Streptococcus, Bacteroides fragilis, Proteus, E.coli, Staph aureus
* Candida, Aspergilla, Cryptococcus
* Toxoplasma, Taenia solium.

183) (RMedEd
 MedEd FARRE: Microbiology

o Subdural and epidural empyema: Collection of pus below and above the dura
respectively.
o Staph aureus and others are similar to brain abscesses
o Cystic parasitic disease - Taenia solium.
Approach to a patient with probable CNS infection:
o Take proper history
o
High-grade fever, neck rigidity, photophobia, and projectile vomiting point
towards acute wmeningitis
o Fever with weight loss, cranial nerve palsies, cough, and decreased appetite point
towards tubercular or other chronic forms of meningitis
o Behavioural changes, seizures, and altered sensorium point towards encephalitis
as a cause.
O A
triad of high-grade fever, focal neuological deficits and severe headache point
to a focal brain abscess.
Examination:
o Look for Kernig and Brudzinski sign for meningitis
o
Cranial nerve involvement or stroke-like features seen in tubercular meningitis
o Focal neurological deficits in localised brain abscess
Investigation:
o CSF study
O Blood cultures
o Sputum analysis for TB
O MRI and CT Scan
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 687

184
CNS Infections

CNS

77. A 35-year-old traveler presents with fever, fatigue, muscle pain

He recently returned from a trip to Southeast Asia. Diagnosis: Japanese encephalitis
is suspected due to travel history, confirmed through blood tests for virus-specific
antibodies

(A) what are the causes of encephalitis?

(B) What are the features and laboratory diagnosis of encephalitis?
(C) Write a note on Japanese encephalitis. (5 marks)
Answer:
(A)
o Encephalitis is an acute inflammation of the brain parenchyma caused by the
invasion of infectious agents majority are viruses.
The causes of encephalitis are
o Herpesvirus
* HSV1>HSV2
CMV
HHV%
> Varicella virus
* EBV
o Arboviruses
JE
West Nile viruS
O Rabies
o Nipah and Hendrix virus. etc.
(B) Clinical features of encephalitis
o ln acute febrile illness, patients with encephalitis often present with
* Altered mental status.
Seizures: focal or generalized seizures.
> Neuropsychiatric symptoms: hallucinations, agitation, personality changes,
behavioral disturbances, are present.
* Focal or diffuse neurologic symptoms: The most common focal findings are
aphasia, ataxia, debilitating patterns of upper or lower motor neurons,
involuntary movements, and cranial nerve deficits.
* Involvement of the hypothalamic -pituitary axis can lead to hyperthermia,
diabetes insipidus, etc.

18 RMedEd
CNS Infections

MedEd FARRE: Microbiology

Laboratory diagnosis:
o CSF Analysis: The characteristic CSF profile in encephalitis is indistinguishable from
that of viral meningitis. It consists of lymphocytic pleocytosis, slightly elevated
protein levels, and normal blood sugar levels.
o Viral markers in CSF are identified using PCR
o Antibodies detection in CSF by ELISA
(C) JE virus is the most common cause of vaccine-preventable encephalitis in lndia.
o It is an ssRNAvirus belonging to the family Flaviviridae and its vector is the Culex
mosquito.
Transmission cycle of JE virus:
Two transmission cycles are predominant
O Animal Host: JE virus as multiple animal hosts.
> Pigs are considered primary hosts of JE. JE viruS grows exponentially in pigs
without showing symptoms. Pigs are considered an amplifier for JE.
* Cattle and buffaloes can also be infected with the JE virus. They are not natural
hosts but can act as mosquito attractants.
* Horses are probably the only animals that show symptoms and develop
encephalitis after being infected with the JE virus.
* Humans are considered a dead end.
o Bird hosts: Herons, cattle egrets and ducks may also be involved in the natural
cycle of JE virus.
Clinical features:
The clinical course of the disease can be divided into three stages.
O The prodromal stage a febrile illness. Onset is either sudden (1-6 hours), acute
(6-24 hours), or more commonly subacute (2-5 days).
o Acute encephalitis stage: JE is the most common cause of acute encephalitis syndrome
(AES) in lndia which is characterized by acute fever, confusion, disorientation,
delirium, seizures, or coma.
Laboratory Diagnosis:
o lgM Capture Antibody (MAC) ELISA
o RT-PCR detect the JE virus-specific envelope gene (E) in blood.
Treatment:
O Supportive measures Only
Preventive measures:
O Live attenuated SA 14-14-2 vaccine
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 715

186)
CNS Infections

78. Write a short note on Acanthamoeba encephalitis. (S marks)

Answer:
Introduction
O Acanthamoeba species are free-living amoebas
that infect the central nervous
System, skin, and eyes.
o They are isolated from soil, fresh and brackish water.
Morphology
o It occurs naturally as cysts and trophozoites form.
There are no flagellated forms.
O Trophozoites: 30 um in size and characterized by the presence of spiny pseudopodia
called acanthopodia. The nucleus is single, with a central karyosome and no
peripheral chromatin. Trophozoites must be carefully distinguished from pus cells
by their motility observed on wet mount examination.
o Cysts: 10-25 um in size, double-walled, outer wall of cyst wrinkled appearing.
Life cycle
and etiology
o Humans become infected by inhaling cyst- or trophozoite -contaminated aerosols
or, rarely., by direct spread through skin lesions or infected eyes. The main sites of
infection are the sinuses and lungs.
o Trophozoites enter the CNS via the hematogenous route from the lungs.
o These cause two important clinical syndromes.
GAE (granulomatous amebic encephalitis) in immunocompromised patients,
Keratitis in contact lens wearers
Granulomatous amebic encephalitis (GAE)
GAE begins insidiousty, with incubation periods that vary from weeks to months.
o Pathology: Focal granulomatous lesions develop in the brain. cSF lymphocytosis
may be observed. However, no cells are found in the CSF of AIDS patients.
o Symptoms: Confusion, dizziness, nausea, headache, stiff neck, and sometimes
seizures and hemiplegia.
o In HIV patients: ln addition to GAE, Acanthamoeba causes nasal ulcers, skin ulcers,
and musculoskeletal abscesses.
Laboratory Diagnosis
o cSF Microscopy: CSF is the specinen of choice for GAE.

The presence of characteristic trophozoites (or sometimes cysts) confirmns the

diagnosis.
* Wet mount inspection and phase contrast microscopy are performed.

187 (i MedEd
CNS Infections

MedEd FARRE: Microbiology

LABORATORY DIAGNOSIS

Specimens such as CSF, blood or skin scrapings can be collected.

Direct Detection Methods Negative staining:
O Modified lndia ink stain (added with 2% mercurochrome)
and nigrosin stain are
used to demonstrate the capsule, which appears as refractile delineated clear space
surrounding the round budding yeast cels against a black background Capsules
may be twice as thick as the diameter of yeast cells lndia ink stain is less sensitive
(60-70%),.
o Gram staining may show gram-positive round budding yeast cells
O Other stains include:
* Mucicarmine stain: It stains the carminophilic cell wall of C. neoformans
3 Masson-Fontana stain: It demonstrates the production of melanin
Alcian blue stain to demonstrate the capsule.
O Antigen detection: The capsular antigens can be detected from CSF or serum by
latex agglutination test.
o Culture CSF is inoculated onto SDA without antibiotics, blood agar or chocolate
agar and incubated at 37°C. Blood is inoculated on biphasic cultures and if the
fungus ispresent it's colonies appear as mucous creamy white in nature.
o Confirmation
* Bird seed agar and Niger seed agar
Urease test positive
* lnositol and nitrate assimilation
* MALDI-TOF
* Pathogenicity test in mouse
Treatment:
o Without CNS involvement- Fluconazole
o lmmunocompromised with CNS involvement
* induction phase of 2 weeks of AmphoB along with fluticasone
• continuation phase with fluconazole
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, Brd
Edition, Page No. 734

192)
CNS Infections

CNS

81. Leena a 26 yr old female came to the ER with muscle stiffness and spasms,
unable to open her mouth due to jaw lock. Past Wo She had stepped on a rsty
nail a week ago, didn't seek medical care, and wound became infected.
(10 marks)
(A) What the probable diagnosis? How will you confirm the diagnosis?
(B) What is the pathogenesis of the infection and mechanism of muscle stiffness?
(C) What is the treatment and prevention?
Answer:
(A)
Based on the given clinical history the probable diagnosis is tetanus infection.
Lab diagnosis:
Specimen collection: It should be taken from the depths of the wound. The tissue
O

specimen is more reliable than a swab from the wound pus

o Staining: Gram stain reveals gram-positive bacilli which have a terminal spore
giving ita drumstick appearance
O Culture:

* RCB Shows proteolytic i.e. black solution if tetanus is present. Other species are
saccharolytic hence produce pink colonies
* Blood agar with polymixin B shows swarming growth in anaerobic conditions
for 24-48 hrs.
O Toxin assays: ln Vivo mouse inoculation test

193 RMedEd
CNS Infections

MedEd FARRE: Microbiology

(B) PATHOGENESIS

Pathogenesis of tetanus

Mechanism ofaction
Virulence factors
QUMN
Rewshaw cel

Muscle fibre
Tetnospasmin
Tetanolysin
LMN
Itis antigenic in nature
Neurotoxic produce the Tetanus toxin.
Itis a hemolysin disease symptoms by
Not much role in -affecting GABA-nergic Act on renshaw cell and inhibit release of
virulence neurons in spinal cord. GABA

Excessive activation of LMN

Muscle fibres stays in a state of spasm

Thus leading to spastic paralysis

Clinical features:
o These are mostly due to increased activation of lower motor neurons therefore
present as stiffness.
o Trismus or lockjaw is the first symptom while in neonates it is difficulty in feeding.
o tt slowly progress descending spastic paralysis
o The DTR are exaggerated.
o Autonomic disturbances can also occur
Complications:
o Risus sardonicus: sustained spasm of the masseter muscle giving a grinning look
on face
o Opisthotonos: Due to generalised extensor muscle spasm there abnormal body
posture
o Death due to spastic paralysis of diaphragm.

194)
CNS Infections

CNS

L(C) TREATMENT
O Passive immunisation:
* HTIG (human tetanus immunoglobulin)
* ATS (anti tetanus serum) derived from horse.
O Dosage 250 IU of HTIGsingle dose M.
Effect last for 30 days.
o Combined immunisation- Give both active and passive immunisation ie. TT with
HTIG
o
Other supportive measures to sustain breathing and respiration by endotracheal
intubation
O Wound treatment by surgical debridement.
Prevention of tetanus:
o By giving active immunisation: TT or tetanus toxoid is the inactivated formn of the
main virulent exotoxin of the bacteria.
o In children given in combination as DPT while in adults as Td
o It is given IM at thigh anterolateral aspect in children and on deltoid in adult.
o It is also known as sth day disease where neonates looses ability to suck and cry.
It should be promptly identified and treated.
o
The neonate should be vaccinated according to the NIS.
TetanuS schedule under NIS is:
O 3 doses in pentavalent at 6, 10, 14 weeks of age
o 2 booster dose of DPT at 16-24 weeks and at 5 years of age
o Two dose of Td at 10 and 16 years of age.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 702

195) (KMedEJ
CNS Infections
O Neurocysticercosis (NCC): Accounts for 60-q0% of cases, is the most common
a
form, and is major cause of adult epilepsy worldwide. it primarily affects adults
between 3o and so years old and can be parenchymal or extraparenchymal.
Symptoms of NCC: Seizures (70% of cases), hydrocephalus, increased intracranial
O
pressure, headache, vomiting, dizziness, chronic meningitis, focal neuropathy,
mental disorders, dementia, cerebral arteritis (with subarachnoid cyst), and basal/
ventricular involvement.
o NCC Stages: Vesicular, necrotic, nodular, and calcified stages.
O NCC and HIV: Co-infection with HIV is increasingly likely and should be recognized
in HIV patients.
Other Forms of Cysticercosis:
o Subcutaneous Cysticercosis: Often asymptomatic, may present as palpable nodules.
o
Muscle Involvement: Manifests as muscle pain, weakness, or pseudohypertrophy.
o Ocular Cysticercosis: Affects eyelids, conjunctiva, and sclera, causing symptoms
like proptosis, double vision, vision loss, and slow-growing nodules with localized
inflammnation.
(C) Laboratory Diagnosis
o Radiological Investigation: CT and MRI are used to identify the number, location,
size, and stage of cysts.
Immunodiagnosis: Includes antibody detection by ELISA, Quick ELISA, Western
Blot, and antigen detection in CSF or serum by ELISA.
o Histopathology: Cysticerci can be detected in muscle, eye, subcutaneous tissue,
or postmortem brain through surgical removal or biopsy following fine needle
aspiration. Microscopic inaging distinguishes viable, necrotic, and calcified cysts.
o Fundoscopy: Visual confirmation of larval movement and morphology.
Treatment:
o Parenchyma Lesions: Treated with Albendazole or Praziquantel.
o Symptomatic Treatment: Includes anti-epileptic medication for epilepsy and
steroids to reduce brain inflammation, preventing hydrocephalus.
o Surgery: Generally not performed.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 735

197 MedEd
< CNS Infections

MedEd FARRE: Microbiology

83. Write a short note on bacterial meningitis. (10 marks)

Answer:
o Definition: Acute bacterial meningitis is an acute onset purulent infection in the
subarachnoid space characterised by increased polymorphonuclear cells in the CSF.
o Predisposing factors: Age group, cSF shunts, BBB integrity and inmmunization
Causative agents of acute meningitis:
o Bacterial: Streptococcus pneumoniae, Neisseria meningitides, Haemophilus
influenza, E.coli, Streptococcus agalactiae, Listeria monocytogenes,
o Viral: Enterovirus, Herpes virus etc
o Parasitic:
Naegleria fowler.
Causative agents of chronic meningitis:
o Bacterial: Tuberculosis, Borreliosis, Syphilis, Tropheryma whipplei.
O Parasitic: Acanthamoeba, NCC
o Fungal: Candida and Cryptococcus.
Clinical features:
o High Fever: Sudden onset of high fever, often accompanied by chills.
o Severe Headache: Intense, throbbing headache that can be accompanied by neck
stiffnes.
o Neck Stiffness: Difficulty in flexing the neck forward due to inflammation of the
meninges.
o Photophobia: Sensitivity to light, which can cause discomfort or pain in well-lit
environments.
O Nausea and vomiting: Many patients experience nausea and vomiting due to the
Severe headache.
o Confusion or Altered Mental State: Patients may become disoriented or confused,
especially as the infection progresses.
o Skin Rash: In some cases, particularly with Neisseria meningitidis infections, a
distinctive skin rash may develop.
Clinical signs:
o Kenig's: Kernig's sign involves pain and resistance when extending the leg at the
knee while the hip is flexed.
o Brudzinski's Sign: It is the involuntary flexion of the hips and knees when the neck
passively flexed.

98
< CNS Infections

MedEd FARRE: Microbiology

o Streptococcus pneumoniae
* Culture: a-hemolytic colonies on blood agar, k/a draughtsman-shaped or carrom
coin appearance
Biochenical test: bile soluble, ferments inulin and optochin sensitive
O Neisseria meningitidis
* Culture: produces non-hemolytic colonies on blood agar, on smear shows gram
negative diplococci
* Biochemical test: catalase and oxidase positive. They ferment glucose and maltose
but not sucrose
* Serogrouping: Slide agglutination serogrouping (SASG) test is done to identify
the serogroups of meningococcus.
o Haemophilus infuenza
* Culture: Blood agar with S. aureus shows satellitism.
» Biochemical test: factor requirement growth surrounding combined X and V
disk
o Streptococcus agalactiae
* Culture: B-hemolytic colonies on blood agar, on smear shows gram-positive
cocci in short-chain
Biochemical test: It shows CAMP test positive and resistance to bacitracin
* Serogrouping: shows Lancefield group B
o Gram-negative bacilli meningitis
Escherichia coli and Klebsiella produce lactose-fermenting colonies on MacConkey
agar; identified by ICUT tests
Non-fermenters: Pseudomonas is oxidase positive, whereas Acinetobacter is
oxidase negative. They produce non-lactose fermenting colonies; identified by
ICUT tests
o Listeria monocytogenes
> Motility: tumbling motility at 25°C whereas it is nonmotile at 37°C (called
differential motility, which is due to temperature -dependent flagella expression)
* Culture: It grows on blood agar (B-hemolytic colonies), and chocolate agar.
Selective media such as PALCAM agar (containing a mixture of antibiotics) may
be useful.

200
 C'NS

Pathogenesis:
o Poliovirus is transmitted by the fecal-oral route (most common), followed by
respiratory droplets from inhalation or, rarely, by contact with the conjunctiva.
o Local proliferation: It proliferates in intestinal epithelial cells, submucosal lymphoid
tissue, tonsils, and Peyer's patches.
o Receptor: Virus entry into the host cell is mediated by binding to the CD155
receptor on the host cell surface.
CNS/Spinal Spread:
o Hematogenous spread (Most comwmon):
o Nerve spread: Viruses can also spread directly through nerves. This is especially
true after tonsillectomy,
o Site of Action: The final target of the poliovirus is motor nerve endings, Anterior
horn cells of the spinal cord are damaged, causing muscle weakness and flaccid
paralysis.
o Degeneration of neurons: Neurons infected with viruses undergo degeneration.
The earliest change in neurons is the degeneration of Nissl bodies, aggregated
ribosomes usually found in the cytoplasm of neurons.
Clinical features:
The incubation period is usually 7-14 days. Symptoms range from
O Asymptomatic infection: After infection, the majority of cases are asymptomatic.
o Abortion infection: Some of the patients have nild symptoms such as fever,malaise,
sore throat, loss of appetite, muscle pain, and headache.
o Non-paralytic polio: Aseptic meningitis is seen in 1% of patients,
o Paralytic polio being the rarest form (less than 1%) of all stages. It is characterized
by descending asymmetric acute flaccid paralysis (AFP) .Proximal muscles are
affected earlier than distal muscles. Paralysis begins at the hip joint and progresses
tothe extremities. This leads to the characteristic tripod sign.
o Biphasic course: ln children, the course of the disease is usually biphasic. Aseptic
meningitis initialy develops resolves -fever with paralytic symptoms recurs
1-2 days later
Laboratory diagnosis:
o Samples collection: Poliovirus can be detected in throat swabs (up to 3 weeks from
onset) and rectal swabs or stool samples (up to 12 weeks).h
o Virus isolation from CSF or blood is very rare. Transport: Specimens should be kept
frozen during transport to the laboratory.
o
Cell Lines: Primary monkey kidney cells are the cell line of choice. Viral growth
can be identified using a variety of methods. Cytopathogenic effects appear after
3-6 days.

20 (RMedEd
 MedEd FARRE: Microbiology

o Antigen detection: Isolated viruses can be identified and serotyped by neutralization

with specific antisera or by immunofluorescence. PCR test is available that targets
the VP1 region of poliovirus.
o
Antibody Detection Elevated antibody titers in paired sera collected one to two
weeks apart are indicative of polio.
o Molecular methods: Real-time multiplex reverse transcriptase PCR was developed
using primers for the VPI region.
Polio vaccine:

Polio vaccine Injectable vaccine (Salk) Oral vaccine (Sabin)

Formulations IPVcontains three o Trivalent OPV
serotypes 1, 2 and 3 (serotypes 1, 2 and 3)
o Bivalent OPV (serotype
1 and )
O Monovalent OPV (any
one serotype)
National immunization It can be given in two Total five doses (2 drops/
schedule (India, 2020) doses: Full dose IPV and dose, oral) of bivalent
fractional-dose (f-IPV) OPV (serotype 1 and 3):
Two fractional doses O Zero dose-given at
(intra-dermal route at birth
upper arm, O.1 m/dose):
Given at Gth and 14th 1st, 2nd and 3rd
weeks of age along with dose -given at 6th,
10th, 14th week of
bivalent OPV age; booster given at
16-24 months
|Local immunity Not provided Strongly stimulated (due
to lgA)
|Herd immunity Not provided Provided
VAPP and VDPV Zero chance Relatively more chance
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 709

204)
 CNS

85. A 7 yr old boy comes to the emergency with his parents. The parents complain
that the child is having a fear of water and is producing barking sounds like a
dog. On probing the child admits that 6 weeks back he got bit by a dog but he
did not tell anyone and did some wound dressing on his own. The is almost healed
but he is having neurological symptoms.
(A) what s the likely diagnosis?
(B) What is the Pathogenesis, clinical features and laboratory diagnosis.
(C) What are pre and post exposure prophylaxis measures? (20 marks)
Answer:
(A) The probable diagnosis is Encephalitic abies caused by rabies virus.
(B) Morphology

RNA polymerase
Glycoprotein

Lipid Bilayer
M (matrix protein)

Negative sense RNA strand

nucleocapsidprotein

o Bullet shaped RNA virus

o G protein are most important as responsible for the Pathogenesis of the virus as
well as used in vaccine development.
Transmission:
o Animal Bite: Most cases are due to dog bites. Other are bat foxes etc.
o Non bite exposure: Direct contact with infected mucosa or inhalation of virus or
corneal or organ transplantation.
 MedEd FARRE: Microbiology

Virus spread:
O Local replication: The virus begins to multily locally at the site of inoculation in
muscle or connective tissue.
o
Viral entry into peripheral neurons: The virus binds to nicotinic acetylcholine
receptors at the neuromuscular junction.
o Spread to neurons: The rabies virus spreads afferently along peripheral motor
nerves by retrograde rapid axonal transport. It reaches the dorsal root ganglion
of the spinal cord and then ascends towards the CNs.
o CNS
Infection: Spreads rapidly to various sites. The most common locations in the
CNS are the hippocampus and cerebellum. Spreads to various locations centrifugally
from there, but there is no virewmia.
O Salivary shedding
o Pathological changes: The presence of Negri bodies (cytoplasmic eosinophilic
inclusion bodies) composed of rabies virus protein and viral RNA
Clinical manifestations:
O lncubation period is long and variable, averaging 20-90 days.
o This is directly related to the distance the virus travels from the vaccination site
to the CNS. Therefore, the incubation period is usually shorter in children than in
adults.
o
The clinical spectrum he is divided into three phases as follows:
* The prodromal phase: characterized by nonspecific symptoms such as fever,
malaise, anorexia, nausea, vomiting, photophobia, sore throat, and dysesthesia
at the wound site
o Acute neurological stage: This can be either encephalitic (80%) or paralytic
(20%).
Encephalitic or Violent Rabies: Hyperexcitability: May cause anxiety, agitation,
hyperactivity, strange behavior and hallucinations.
o A period of hyperexcitability is usually followed by complete lucidity,
o Autonomic dysfunction such as lacrimation, salivation sweating, goose bumps,
arrhythmia, and priapism may also occur.
o Hydrophobia (fear of water) or aerophobia (fear of air): Paralytic or dull rabies:
This occursespecially in partially vaccinated people or those infected with the bat
rabies virus. It is characterized by flaccid paralysis.
O Coma and death.

LABORATORY DIAGNOSIS
O
Antigen Detection by Direct Immunofluorescence (Direct-IF): The DEA test is
considered the "gold standard" method for diagnosing rabies due to its hiqh
sensitivity and specificity. The best sample is the hair follicles on the back of the
neck (the most sensitive).
 CNS
o Virus -isolated in mice
o Cell lines: Mouse neuroblastoma cell lines and baby hamster kidney (BHK) cell lines
are the preferred cell lines for rabies virus isolation
O Antibody Detection: In CSF is more siqnificant than serum antibodies. Serum
antibodies appear late and can also be present after vaccination by IFA, mouse
neutralisation test.
O Viral RNA Detection-RT-PCR can be used
o Negri's body recognition helps confirm the post-mortem diagnosis of rabies.
(C) There is no
treatment for rabies once the infection spreads to the brain only
symptomatic management to extend the life.
o Prevention is the most important way of curtailing this disease.
Rabies vaccines:
o Purified chick embryo cell vaccine: It is prepared from chicken fibroblast cell line
Purified Vero cell (PVC) vaccine
o Human diploid cell (HDC) vaccine
Pre-exposure prophylaxis:
Regimen for PrEP- can be given to individuals of all ages. Schedule: Two schedules
are available
o 2-site ID vaccine given on days O and 7
O 1-site IM vaccine given on days o and 7.

o Booster: PrEP is likely to provide lifetime protection

Post exposure prophylaxis:
PEP regimen schedule:
o ID PEP regimen (2-2-2): 2-site ID vaccine is given on days O, 3 and 7
O IM PEP regimens: Total four doses are given. Two schedules are available

*1-site IM vaccine given on days O, 3, 7 and the fourth dose between days 14
to 28 or
* 2-site IM vaccine given on day o and 1-site IM on days 7 and 21.
Rabies immunoglobulin (RIG):
O These provide passive immunity and can be administered with 7 days of first dose
of vaccine
o These antibodies directly neutralise the virus.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. 718

207) (MedEd
 MedEd FARRE: Microbiology

86. Write short notes on: (10 marks)

(A) Toxoplasma encephalitis (S)
(B) Prions disease (5)
Answer:
L(A) INTRODUCTION

o ToxoplaSma gondi is an obligate intracellular parasite.

o
Human infections are common, but cause disease in HIV/AIDS (leads to encephalitis)
and congenital infections in the fetus.
Morphology
O
it has 3 morphological forms, two asexual forms (tachyzoites and tissue cysts) and
One sexual form(oocysts).
o Tachyzoites are the actively reproducing form (trophozoite) that is usually seen in
acute peripheral blood infections.They are crescent-shaped.over time, host cells
expand through proliferating tachyzoites and appear as pseudocysts.
o Tissue Cyst: This is the dormant phase of the parasite that usually occurs in chronic
infections.
* Tissue cysts, composed of multiple bradyzoites surrounded by a cyst wall.
* Bradyzoites are crescent-shaped, slowly regenerating trophazoites.
o Oocyst is the seKual form of the parasite found in cats.
o Lifecycle

208
 CNS

Man acquire infection

Forms sporulated cyst 3

in environment Sprozoites or
bradyzoites released

Unsporulated oocyst
Tachyzoites.
in cat feces
Human cycle
Feline cycle intermediate host
Fertilization & definite host Spreads to lymph
formation of zygote nodes.

fetus
Formation of male and
female gametocyles

Extraintestinal spread to
eyes, muscles, brain etc

Bradyzoites in cats
intestine

Bradyzoites.
Cat acquire infection

Tissue cyst

H934 -Routes of
infection

PATHOGENESIS
Various risk factors for infections include:
O
tmmune status: Patients associated with HIV, malignancies, other immunodeficiency
diseases are at high risk.
o Diet: Consumption of raw cat meat.
O
High risk Genetic factors: HLA DQ3 isassociated with encephalitis in AIDS patients
and hydrocephalus in Toxoplasma -infected fetuses.
Clinical manifestations
o Immunocompetent: is usually
asymptomatic and self-limited.
O
Lymphadenopathy: The moSt common symptom is cervical lymphadenopathy.
Other lymph nodes may also be affected.

209 GMedEd
 MedEd FARRE: Microbiology

o Toxoplasmosis in HIV patients infection occurs as a result of reactivation of latent

infection. it causes Toxoplasma encephalitis (TE).
Toxoplasma encephalitis:
o it affects brainstem, basal ganglia, pituitary gland, and corticomedullary junction.
o Patients experience altered mental status, seizures, paresthesias, cerebellar
symptoms and focal neurological deficits.
Laboratory Diagnosis:
o Direct Microscopic Examination: The specimens frequently examined are peripheral
blood, body fluids, lymph node aspirate, bone marrow aspirate and biopsy material
from spleen, liver and brain.
o Tissue cyst containing strongly PAS positive bradyzoites can be detected in various
tissues like brain or muscle.
o
Antibody detection: remains the most widely used method for diagnosing acute
toxoplaswnosis in immunocompetent persons.
* lgG antibodies: Diagnosis of acute toxoplasmosis requires a 4-fold increase in
lgG titer.
* lgG avidity test: The avidity of lgG and its antigen increases over time.Evidence
of low lgG avidity indicates recent infection (less than 12 weeks).On the other
hand, strong avidity indicates previous infection.
* lgM antibodies: Early appearance, within 1 to 2 weeks. It therefore indicates
acute infection, but is not a reliable indicator as it lasts up to 6 months.
o Simultaneous lgG and lgM tests are interpreted as followS:
> lga (+) and lgM (+): indicate acute infection, but require further confirmation
by lgG avidity test.
* tga (+) and lgM (-): indicate T.gondii >6 months ago (remote infection)
* lga (-) and lgM (+): indicates false positive tgM.
o Sabin-Feldman Dye Test- This is a complement-mediated neutralization test that
requires live tachyzoites.
o Molecular diagnostics: PCR can be used to detect DNA
o Imaging methods: CT or MRI scan of her brain can be performed to detect multiple
ring-enhancing lesions in the basal ganglia or corticomedullary junction.
o CSF Testing: Increased ICP, lymphocytosis, slightly elevated protein concentrations,
occasionally elevated levels of gamma globulin, and normal blood glucose levels.
L(B)
o
Prions: lnfectious protein particles devoid of nucleic acids.
o Resistant to Sterilization: Prions are resistant to chemical and physical sterilants.

210
 CNS

O Prion Diseases: Exist in humans and animals.

Mechanism:
o Prions induce misfolding of nornal cellular prion protein (PrPC) to form the
disease -causing isoform (PrPSc).
o PrPSc aggregates as amyloid-ike plaques in the brain.
o Taken up by neurons and accumulates in cytoplasmic vacuoles.
o
Leads to spongy appearance in cells, inherited by offspring.
Clinical Features:
o Incubation period varies (months to up to 30 years).
o Rapid disease progression.
o Prodromal phase (3-5 months), followed by symptoms: loss of muscle control,
tremors, myoclonic spasmns, coordination loss, and dementia.
O Death within a year of disease onset.
Human Prion Diseases:
Kuru: Spread through ritual cannibalism of infected deceased relatives.
Creutzfeldt-Jakob Disease (CJD):
o
Most common human prion disease.
o Associated with dementia and myoclonus.
o
Progressive and usually fatal within a year.
o Types:
o Classical or sporadic (85% of cases): Spontaneous misfolding.
* Familial (15% of cases): Inherited mutations.
Variant (vCJD): Develops before age 30
Laboratory Diagnosis:
o Measurement of PrPSc by conformation-dependent immunoassay.
o Neuropathological diagnosis on brain biopsy: Spongiform degeneration without
inflammatory response.
o Abnormal EEQ: Shows late-phase sharp, high-voltage discharges.
Treatment:
o No available treatment for prion diseases.
Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. 731, 725
Urogenital Infections

Urogenital Infections
87. Write the causes of urinary tract infection along with laboratory diagnosis of UTI.
(5 marks)
Answer:

Bacterial agents Other agents

Enterobacteriaceae Fungus
O Escherichia coli: Most commnon o Candida albicans
o Klebsiella pneuwmoniae
o Enterobacter species
o Proteus species
o Serratia species
Non-fermenters
o Pseudomonas aeruginosa
O Acinetobacter species
Gram-positive bacilli Parasites
O Mycobacteriumn tuberculosis O Schistosoma haematobium
o Trichomonas vaginalis
o Dioctophyme renale
Gram-positive cocci Viruses
o Enterococcus species o BK virus
o
Staphylococcus species O Adenovirus

Laboratory diagnosis of UTI:

Proper specimen collection is crucial for accurate diagnosis of UTIs.

o
Clean Voided Midstream Urine
This is the most common method for collecting urine specimens in suspected
UTI cases.

* Patients are instructed to clean the urethral meatus (the external opening of the
urinary tract) or the glans (in mles) before providing the urine sample.
o Suprapubic Aspiration of Urine from the Bladder:
* Considered the most ideal specimen collection method.
* Recommended for patients who are in a coma or for infants who cannot provide
a clean voided sample.

210
< Urogenital Infections

Urogenital infections

o Catheterized Patients:
* In patients with indwelling urinary catheters, urine should be collected directly
from the catheter tube.
Urine should not be collected from the uro bag (a drainage bag attached to the
cathetern)
Transport and Examination of Urine Samples:
o
Urine samples should ideally be processed immediately after collection.
o
If there's a delay of more than 1-2 hours before processing, the sample can be
stored in the refrigerator.
o Another method for longer storage (up to24 hours) is by adding boric acid to the
urine sample.
Direct Examination (Screening Tests):
O Wet Mount Examination: This test aims to demnonstrate the presence of pus cells
in urine.
o Leukocyte Esterase Test: This detects leukocyte esterases produced by pus cells in
urine.
O Nitrate Reduction Test (Griess Test): It identifies nitrate-reducing bacteria like E.
coli. A positive result indicates the presence of these bacteria.
Gram Staining:
o Gram staining of urine is not always reliable due to several factors, including the
typically low bacterial count in urine and the rapid deterioration of pus cells in
the sample.
o Gram staining may be limited to cases of pyelonephritis and invasive UTIS, where
a count of 21 bacterium per oil immersion field is considered significant.
Culture:
o Urine samples should be inoculated onto appropriate culture media, such as CLED
agar (cysteine lactose electrolyte deficient agar) or a combination of MacConkey
agar and blood agar.
o The concept of "significant bacteriuria" is based on a count of 21Ons colony
forming units (CFU/mi of urine, indicating infection. Counts between 1on4 and
10n5 FU/ml are considered doubtful and should be clinically correlated.
ldentification:
o The colonies grown are identified, either using automated identification systems
like MALDI-TOF or VITEK or through conventional biochemical tests.
Antibody-coated bacteria test
o ln Upper UTI as spread via blood the bacteria are coated with antibodies which
can be detected by fluorescence techniques.
o In Lower UTI no such finding is present.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 745

213) RMedEd
 MedEd FARRE: Microbiology

88. (A) Write a short note on syphilis and DDS of genital ulcers. (10 marks)
(B) Write in brief about the life cycle of chlamydia.

Answer:
Syphilis is classified into two groups based on transmission:
o Sexually transmitted: Caused by Treponema pallidum, leading to syphilis.
O Nonvenereal treponematosis: Caused by T. pertenue, T. endemicumn, and
T. carateum. These are similar to T. pallidum but transmitted by non-sexual
cOntact and produce nongenital cutaneous manifestations.
Clinical Manifestations
o Syphilis passes through four stages if left untreated. Congenital syphilis can affect
newborns.
o Primary Syphilis:
» Characterized by a single, painless, hard indurated ulcer known as a primary
(or hard) chancre.
* Common sites include penis (in males), cervix or labia (in females), anal canal,
rectum, or mouth (in homosexuals).
o
Secondary Syphilis:
* Develops 6-12 weeks after primary lesion healing.
* Characterized by skin rashes, condylomata lata, mucous patches, and generalized
(ymphadenopathy.
o Latent Syphilis:
* Follows secondary syphilis.
* Absence of clinical manifestations but positive serological tests for syphilis.
o Late or Tertiary Syphilis:
* Develops several decades after the initial infection.
• Gummna (granulomatous lesions), neurosyphilis, and cardiovascular syphilis are
manifestations.
Laboratory Diagnosis:
o Direct Microscopy (Demonstration of Treponemes):
* Dark round Microscopy (DGM) is used to visualize Treponema pallidum.
* Treponemes appear as slender, flexible, spirally coiled bacilli with corkscrew
motility.
o Direct Fluorescent Antibody Staining for T. pallidum (DFa-Tp):
Smears from exudates or tissue sections. are stained with luorescent-labeled
monoclonal antibodies.

214)
Urogenitai IecLIUIIS
Urogenital infections

* T. pallidum appears as apple -green fluorescent-colored bacilli.

o Silver Impregnation Staining:
* Used to increase Treponema thickness for easier visualization.
SEROLOGY (ANTIBODY DETECTION)
Non-Treponemal Tests:
o These tests detect non-specific antibodies called reagin antibodies in the patient's
SeruM.
o Reagin antibodies react with cardiolipin antigen derived from bovine heart.
o Reagin antibodies are typically lgG, sometimes lgM, and are distinct from lgE class
reagin antibodies found in type I hypersensitivity reactions.
o Examples of non-treponemal tests include VDRL, RPR, USR, and TRUST.
VDRL (Venereal Disease Research Laboratory):
o it's a precipitation (slide flocculation) test.
O A
positive test (reactive) is indicated by the formation of medium to large clumps
of antigen-antibody complexes.
o CSF antibodies: VDRL can be used to detect antibodies in cerebrospinal fluid (CSF).
o Utility: VDRL is cost-efective and often used as a screening test, for batch testing
(e.g., antenatal screening), and to monitor treatment response.
Rapid Plasma Reagin (RPR):
oA
slide flocculation test using disposable plastic cards with clearly defined circles,
similar to VDRL
o
Used for detecting antibodies in blood, not CSF.

Advantages of Non-Treponemal Tests:

o Recommended for monitoring treatment response.
o VDRL can detect CSF antibodies for neurosyphilis.
o Reagin antibodies become detectable 7-10 days after the appearance of the
primary chancre (or 3-5 weeks after infection).
Treponemal or Specific Tests for Syphilis:
o
TPI (T. pallidum lmmobilization Test):
* Uses live, actively motile T. pallidum (Nichols strain).
*T. pallidum becomes immobilized when it cowmbines with specific antibodies in
the patient's serum.
o FTA-ABS (Fluorescent Treponemal Antibody Absorption Test):
* The patient's serum is layered on a slide previously coated with killed T. pallidum.

215 MedEd
Urogenital Infections

MedEd FARRE: Microbiology

is added, and the slide is
fluorescent-labeled anti-human immunoglobulin
A

examined under a fluorescent microscope.

O Tests That Use T. pallidum Antigen Extracts:
TPHA (T. pallidum Hemagglutination Test)
* TPPA (T. pallidum Particle Agglutination Test)
Western blot and enzyme immunoassay (EIA).
Molecular Methods for Syphilis Diagnosis:
o PCR-based techniques
Genital Chancroid Donovanosis
Features Syphilis LGV
Herpes
Incubation q-90 days 2-7 days 1-14 days 3 days 1-4 weeks
period -6 weeks (up to 6
months)
Genital Painless, Painful, Painful, Painless, Painless,
ulcer |single, multiple, soft, usually firm single single/
indurated bilateral, muttiple, lesion multiple,
tiny purulent, beefy-red
vesicular bleeds easily ulcer, bleeds
ulcers readily
|Lymph Painless, Painful, Painful, soft, Painful Absent
non firm, often marked and soft, (pseudobubo
adenopathyindurated unilateral may be
|bilateral swelling
(firwm). with initialleads to bubo present
episode formation, due to sub
|bilateral
unilateral cutaneous
swelling)
Treatment Penicillin |Acyclovir |Azithromycin Doxycycline Azithromycin
(single dose) (7- 14 (single dose) (21 days) (7 days)
days)

Diferential Diagnosis Laboratory Tests Gram Stain Findings

Herpes Simplex Virus Viral culture, PCR, Tzanck Smear:
(HS) serology (lgG/lgM) |Multinucleated giant cells
with intranuclear inclusions
(Cowary Type A)
Syphilis Serological tests (VDRL, Dark-field microscopy:
RPR, TPPA, FTA-ABS) Spirochetes (Treponema
|pallidum)

(216)
Urogenital Infections

Urogenital infections

Chancroid Culture of Haemophilus Gram-negative coccobacilli

ducreyi
Lymphogranuloma PCR for Chlamydia Intracytoplasmic inclusions
venereum (LG) trachomatis |(reticulate bodies)
Granuloma Inguinale PCR, culture, tissue Donovan bodies
(Donovanosis) biopsy
Life cycle of chlamydia

Forms reticulate
Chlamydia elementary body
bodies attaches tao cell

Divide by binary
fission

Forms
elementary
bodies

Continued
division

Release elementary
bodies

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 756

217 RMedEd
 MedEd FARRE: Microbiology

s9. A 42 year old female presents to the OPD with curdy white discharge from the
vagina. Her RBS came out to be 44Omg/dL. (10 marks)
(A) What is the diagnosis and the most likely cause of it.
(B) Write about the various causes of the disease with laboratory diagnosis?

Answer:
(A) The most likely diagnosis is vulvovaginitis caused by Candida albicans.
(B) Vulvovaginitis is the inflammation of both the vaginal mucosa (vaginitis) and
the extennal genitalia (vulva). It's a cowmmon genital tract infection in females and
typically presents with vaginal symptoms such as abnormal discharge, itching, or
offensive odor. The three most common causes of vaginitis in premenopausal women
are
o Trichomoniasis
o Bacterial vaginosis
o Vaginal candidiasis.
Trichomoniasis is the most common parasitic sexually transmitted infection (STI)
caused by the flagelated parasite Trichomonas vaginalis.
Life Cycle:
O Acquired through sexual contact.
o
Flagellated trophozoites enter the body, transform into amoeboid forms, multiply
in the genital tract, and cause infection.
o They can revert to flagellated trophOzoites, which are discharged in vaginal or
urethral secretions.
Clinical Features:
O Acute infection (vulvovaginitis) in females: Thin, foul-smelling vaginal discharge
(may be frothy and yellowish-green) mixed with pus cells, strawberry appearance
of the vaginal mucosa (hemorrhagic spots).
o
Chronic infection: Milder symptoms like pruritus, pain during coitus, scanty vaginal
discharge mixed with mucus.
Laboratory Diagnosis:
o Direct Microscopy:
* Examine vaginal, urethral discharge, urine sediment, or prostatic secretions.
o Wet mount preparation under a microscope to observe jerky motile trophozoites
and pus cells.
* Other staining methods (e.g., Giemsa, Papanicolaou, acridine orange) can be
used.
o Culture: Process specimens into media like Lash's cysteine hydrolysate.serum media.

218)
 Urogenital infections

O Antigen Detection: Rapid ICT and ELISA using monoclonal antibodies in vaginal
secretion.
Antibody Detection: ELISA to detect antibodies in secretion.
o Molecular Methods: PCR targeting specific T. vaginalis genes (e.g., beta-tubulin
gene).
Supportive Tests:
o Raised vaginal pH (4.5).
o Positive whiff test: Accentuated fishy odor with 10% KOH in vaginal discharge
(positive in trichowmoniasis and bacterial vaginosis).
o lncreased pus cells on wet mount.
Trophozoite Characteristics:
o Pear-shaped.
o Jerky/twitching motility in saline mount.
o Five flagella (four anterior, one lateral - recurrent flagellum).
o Single nucleus with central karyosome and evenly distributed nuclear chromatin.
o Cytoplasm contains siderophore granules along the axostyle.

Free anterior flagella

Nucleus
Recurent flagellum

Undulating membrane Food vacuole

Axostyle

Bacterial vaginosis
It is not and infection just the mere proliferation of bacteria in the vagina.

MedEd
< Urogenital Infections
MedEd FARRE: Microbiology

o Gardenella vaginalis (mwe)

O Mycoplasma hominis
There ae some of the common cauSes of bacterial vaginosis.
Amsel's Criteria (Clinical Diagnosis):
o
Bacterial vaginosis is often clinically diagnosed using Amse's criteria.
o Diagnosis is made if any 3 of the folowing 4 findings are present:
* Slight to moderately increased thin (low viscous), white homogeneous vaginal
discharge uniformly coated on the vaginal wall.
> Vaginal discharge pH greater than 4.5.
* Accentuation of a distinct fishy odor, attributed to volatile amines like
trimethylamine, immediately after vaginal secretions are mixed with a 1O%
solution of KOH (Whiff test).
* Presence of"clue cells," which are vaginal epithelial cells coated with coccobacilli,
showing a granular appearance and indistinct borders on a wet mount.
Nugent's Score (Microscopic Examination):
o Nugent's score is a scoring system used for diagnosing bacterial vaginosis.
Culture:
o Gardnerella vaqinalis requires enriched media such as chocolate agar or BHI broth
with serum.
o It appears gram-variable in smears and forms small pleomorphic rods with
metachromatic granules.
o Hemolytic colonies can be observed on blood agar when incubated aerobically.
Vulvovaginal Trichomonal
Feature Vaginitis Bacterial Vaginosis
Candidiasis
Etiology Candida albicans Trichomonas Gardnerella vaginalis,
vaginalis various anaerobic
bacteria
Typical symptoms Vulvar itching Profuse purulent Malodorous, slightly
and/or irritation discharge; vulvar increased discharge
|itching
Discharge Scanty, white, Profuse, white or. Moderate, thin,
thick and cheesy yellow white to gray
pH of vaginal fluid 4.5 4.5 |Usualy >4.5
Fishy odor with None |May be present Present
10% KOH

220)
< Urogenital Intections
Urogenital infections

Vaginal May be present Colpitis macularis None

inflammation (strawberry
appearance)
(erythema)
Leukocytes, Leukocytes; Clue cells, few
| Microscopy of
vaginal discharge epithelial trophozoites seen. leukocytes, no/few
cells; budding lactobacilli
yeast cell with
pseudohyphae
Other laboratory Isolation of Antigen detection Culture, broad-range
findings Candida spp. or PCR PCR
Treatment Azole cream, Metronidazole Metronidazole
tablet
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 771

221 RMedEd
< Urogenital Infections

MedEd FARRE: Microbiology

40. Explain gonococcal and nongonococcal urethritis. (10 marks)

Answer
O Gonococcal urethritis is a sexually transmitted infection caused by Neisseria
gonorrhoeae, a nonencapsulated, gram-negative, kidney-shaped diplococcus.
Virulence factors
O
Pili or fimbriae: These are the primary virulence factors of gonococci. They facilitate
adhesion to host cells and protect bacteria from phagocytosis.
o Outer membrane proteins: Porin (protein ) forms transmembrane channels that
aid in molecule exchange across the gonococcal surface.
o
Opacity-associated protein (Protein i): This protein assists in adhesion to neutrophils
and other gonococci.
Clinical manifestations of gonorrhea vary between males and females:
In Males:
O Acute urethritis is the most common presentation, characterized by purulent
urethral discharge.
o Untreated cases may lead to complications such as epididymitis, prostatitis, and
balanitis.
o tnfections can spread to periurethral tissues, leading to abscess formation known
as water can peirineum.
In Females:
o Mucopurulent cervicitis common presentation with scanty vaginal discharge.
is a
o
Vulvovaginitis: can occur in prepubertal girls and postmenopausal women with
different vaginal characteristics.
o Fitz-Hugh-Curtis syndrome: complicated form of infection characterized by
peritonitis and perihepatic inflammation.
O in pregnant women, it may cause complications such as premature delivery,
chorioamnionitis, and sepsis in infants.
O in neonates, ophthalmia neonatorum presents with purulent eye discharge and
occurs within days of birth, transmitted during delivery.
LABORATORY DIAGNOSIS
Specimen Collection:
o Preferred specimens for diagnosing gonorrhea are urethral swabs in men and
cervical swabs in women. Vaginal swabs are not as reliable.
o Dacron or rayon swabs are preferred, as cotton and alginate swabs can inhibit
gonococci.

222
< Urogenital Infections

Transport Media:
o Specimens should be transported promptly. If immediate transport is not possible,
specimens can be collected using charcoal-coated swabs in Stuart's transport
medium or Amies medium.
Microscopy:
o Gram staining of urethral exudates can reveal gram-negative intracellular kidney
shaped diplococci.
o Gram staining is highly specific and sensitive in symptonatic men but less so in
wOmen due to the presence of commensal Neisseria species.
Culture:
o Selective media, such as Thayer Martin medium, are used for culturing because
cervical swabs contain normal flora.
o ldentification of the species is crucial to differentiate gonococci from other Neisseria
species. Gonococci are catalase and oxidase positive and ferment only glucose (not
maltose and sucrose).
Molecular Method:
O Nucleic acid amplification tests (NAATS) like PCR are available that target specific
genes like 16s or 23$ rRNA for accurate diagnosis.
Non-Gonococcal Urethritis (NGU):
o Chronic urethritis without the presence of gonococci is termed non-gonococcal
urethritis (NGU). NGU is more prevalent than gonococcal urethritis.
O Bacteria
Chlawmydia the most common causative agent of NGU.
trachomatis: This is

* Urogenital Mycoplasma: Ureaplasma urealyticum and Mycoplasma hominis.

o
Viruses: Herpes siwmplex virus
o Fungi: Candida albicans
o Parasites: Trichomonas vaginalis

Gonococcal Urethritis Nongonococcal Urethritis

Characteristic (NGU)
Causative Agent o Neisseria gonorrhoeae,o Various bacteria, including
a bacterium causing Chlamydia trachomatis,
gonorrhea. Mycoplasma genitalium,
and Ureaplasma
urealyticum, among
others.

223 RMedEd
< Urogenital Infections

MedEd FARRE: Microbiology

|Common Symptoms o Dysuria (painful o Dysuria (painful

urination) - Urethral urination)
discharge (often o
Urethral discharge (clear
yellow or green) or cloudy)
o Frequent urination o Frequency and urgency of
O Genital discomfort urination
o Genital discomfort
Microscopic Examination O Gram-negative O No characteristic
intracellular diplococci microorganisms visible
(GNID) often visible in under the microscope in
urethral discharge. NGU.
Diagnosis o ldentification of O Detection of non
Neisseria gonorrhoeae gonococcal pathogens like
via culture or nucleic Chlamydia trachomatis
acid amplification using NAATS.
tests (NAATS). o No characteristic findings
O Gram staining may on Gram stain.
reveal GNID.
Treatment o Antibiotics effective O Antibiotics that cover
against Neisseria a broad spectrum of
gonorrhoeae, such bacteria, often including
as ceftriaxone and azithromycin or
azithromycin. doxycycline.

Complications o Ifleft untreated, O Untreated NGU can lead

gonococcal infection tocomplications such
can lead to severe as epididymitis in men
complications, and pelvic inflamnmatory
including pelvic disease (PID) in wOmen,
inflammatory disease which may result in
(PID), infertility, infertility.
and disseminated
gonococcal infection
(Da),
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 764

224
Miscellaneous Topics

Miscellaneous
91. What are oncogenic viruses? Explain in brief about the mechanism of oncogenesis
in EBV and HPV infection. (3 marks)
Answer:
O Oncogenic viruses are viruses that have the ability to give rise to cancer of the
infected host cells in the body.
Examples of oncogenic viruses are:
o EBV: leads to Burkitt lymphoma, nasopharyngeal carcinoma, Hodgkin's lymphoma
etc
o HPV: leads to cervical cancer, laryngeal carcinoma etc
o Hepatitis B: causes hepatocellular carcinoma
O HTLV1: causes adult T cell leukaemia.
HPV
o Types 2, 2, 4, and 7 are associated with benign squamous papillomas or warts.
o HPV subtypes 16, 18, 31, 33, 35, and s1 are linked to the developnent of
squamous cell carcinomas (SCCs) in the cervix, and anogenital region, as well as
oral and laryngeal cancers.
o HPV 6 and 11 are responsible for causing genital lesions with low malignant
potential.
O Mechanism: High-risk strains of HPV Produce Eo and E7 proteins. EG inhibits the
p53 protein and E7 inhibits the RB protein causing uncontrolled cell proliferation.
Increased
TERT telomerase Immortalization
expression

HPV E6
p53 Inhibits p53

Increased cell
proliferation

Inhibits p21

Genomic instability
Increased activity
HPV E7 of CDK4/cyclinD

Inhibits Rb

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Ebstein barr virus (EBV)

EBV
apigen
M
LATENT INFECTION
WITH EBV

CD 21 act
as receptor

POLYCLONAL B-CELL
EXPANSION

INCREASED
MYC PROTEIN

OUTGROWTH OF
NEOPLASTIC CLONE:
BURKITT LYMPHOMA

Reference: Essentials of Medical Microbiology, Apurba S Sastry and

Sandhya Bhat, 3rd
Edition, Paqe No. 800

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ISceIIaneOUs

92. Write in brief about the plague. (3 marks)

Answer:

Bubonic Plague Pneumonic Plague Septicemic Plague

Transmission Bite of infected lnhalation of Can result from the

rat flea respiratory spread of bubonic or
droplets pneumOnic plague
Pathogenesis Y. pestis enters Y. pestis enters Involves massive
the body, travels the lungs and blood vessel
to regionat lymph causes pneumonia involvement, leading
nodes, and to skin and mucosal
multiplies hemorrhages
IP About 2-7 days Short, about 1-3 About 2-7 days
days
Clinical Features o Sudden onset o Sudden fever O Massive skin
fever, malaise, o Headache and mucosal
headache hemorrhages
O Painful
o Respiratory O Ganqrene of
Symptoms
lymphadenitis (cough, affected areas
(swollen, tender (historically
hemoptysis,
Iymph nodes dyspnea, chest referred to as the
known as pain)
"black death")
buboes, often
in the inguinal o Highly
area) infectious and
highly fatal
o Potential
dissemination o Bioterrorism
leading to risk, especially
secondary in non-endemic
pneumOnia and regions
meningitis
Laboratory Diagnosis:
o Specimen Collection:
• Bubonic Plague: Pus or fluid from buboes.
* Pneumonic Plague: Sputum and blood.
* Septicemic Plague: Blood and splenic aspirate.
o Direct Microscopy:
* Stains like Gram stain and Wayson stain reveal bipolar or safety pin appearance
of Y. pestis.

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o Culture:
* on blood agar (dark-brown pigmented colonies) and MacConkey
Y. pestis grows
agar (non-lactose fermenting colonies).
o Biochemical Tests:
* Catalase Positive, Oxidase Negative.
ICUT Tests: (-, C-, U

TSI Test: Alkaline/acid reaction, gas absent, H2S absent.

O MALDI-TOF:
* Automated identification system.
o F1 Antigen Detection:
Direct lmmunofluorescence Test.
o ELISA.
* Immunochromatographic Test (1CT).
o Antibodies to F1 Antigen Detection:
ELISA or passive agglutination tests.
O Molecular Methods:

* PCR for targeting Y. pestis genes (F1 antigen, pesticin, plasminogen activator).
Treatment:
o Gentamicin (DOC).

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 809
DO0

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Miscellaneous

93. Write in brief about tularaemia. (3 marks)

Answer:
o Francisella tularensis is the bacterium responsible for causing 'tularemia, a disease
primarily found in rodents and other small animals. Human infection with this
bacterium is typicaly acquired through:
* Interaction with biting or blood-sucking insects, especially ticks and tabanid Flies.
> Ingestion of contaminated water or food.
Inhalation of infective aerosols.
Clinical wmanifestations
O Ulceroglandular tularemia: This is the most common form. It is characterized by
ulcerative lesions at the site of infection, accompanied
nodes.
y
swollen regional lymph

o Other forms include pulmonary, oropharyngeal, oculoglandular, and typhoid -like

illnesses.
o Tularemia can lead to complications such as suppurated lymph nodes, acute kidney
injury, hepatitis, rhabdomyolysis, empyema, pericarditis, wmeningitis, osteomyelitis,
and endocarditis.
o Due to its high infectiousness, F. tularensis is classified as a category A agent of
bioterrorism.
LABORATORY DIAGNOSIS
Specimen collection
o Preferred specimens for testing include ulcer scrapings and lymph node biopsies.
Strict biosafety precautions, such as biosafety level I, must be followed when
handling clinical specimens to prevent laboratory-acquired infections.
Culture
oF. tularensis is highly fastidious
o
Special media like BCG agar (blood cysteine glucose agar) are required for isolation.
Species identification
o Conventional biochemical tests or automated identification systems like VITEK.
Antibody detection
o Agglutination tests (latex and tube agglutination) and ELISA formats are available.
Molecular tests
o
PCR assays
Reference: Essentials of Medicat Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. 810

229 KMedEd
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MedEd FARRE: Microbiology

94. Enumerate emerging and re-emerging infections. (3 marks)

Answwer:

Emerging tnfections
o These are infectious diseases that have shown an increased incidence in the past
20 years or pose a threat of increased incidence in the near future.
Examples O Parvovirus B-19
o Plasmodium knowlesi (a malaria parasite)
O
MERS-Cov (Middle East Respiratory Syndrome Coronavirus)
o SFTS Virus (Severe Fever with Thrombocytopenia Syndrome
virus)
o Nipah virus
o SARS-CoV-2 (responsible for CoviD-14)

Re-emerging Infections
o These are infections that were previously known but had become clinically silent
or had a low incidence. They have re-emerged due to factors like antimicrobial
resistance or the breakdown of public health measures.
Examples O Vibrio cholerae 0134 (causing cholera)
o Plague
O Diphtheria
o Chandipur virus
o Chikungunya virus

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. Annexure 3
D00

230)
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Miscellaneous

95. What are vector-borne diseases? Enumerate with examples. (3 marks)

Answer:
o Vector-borne infections are diseases that are spread by vectors.
o Vectors are living organisms that transmit the infectious pathogen to humans
Type of Vector Common Examples of Diseases
|Anopheles mosquito |Malaria,
Culex mosquito Filariasis, Japanese encephalitis
Aedes mosquito Yellow fever, Dengue, chikungunya.

Ticks Lyme disease, Rocky Mountain spotted fever

Fleas Plague, Typhus

Sandflies Leishmaniasis
Triatomine bugs Chagas disease
Tsetse flies |African trypanosomiasis (Sleeping sickness)
Blackflies Onchocerciasis (River blindness)

Lice Typhus

Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. annexure 7

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96. Explain the brief about the common congenital infection. (5 marks)
Answer:

Clinical Features Laboratory Transmission

Diagnosis
Congenital
Toxoplasmosis
o often asymptomatic
in infants but can
o for
serological testso Highest risk
antibodies is in the third
cause: (lgM and lgG) trimester
O Jaundice o PCR for
o Seizures Toxoplasma
O
gondii DNA
Anemia
o Enlarged liver/ o lmaging
(ultrasound
spleen Or MRI) to
o Ocular abnormalities detect brain
O Hearing loss abnormalities
O Neurological
cOmplications
|Congenital May lead to: o Serological o Highest risk
Rubella o Classic triad (heart testing to is during the
defects, deafness, detect rubella first trimester
eye abnormalities) specific lgM but can occur
o Low birth weight, antibodies in throughout
neonatal blood pregnancy
growth retardation
o o Viral culture or
Neurological PCR from blood
abnormalities or throat swabs
Congenital CMVSymptoms can include:o PCR or viral O Can occur at
Infection culture from any time during
|o Microcephaly
urine, saliva, or pregnancy
o Seizures blood
o Petechiae O Detection of
o Hepatosplen CMV-specific
omegaly lgM antibodies
o Sensorineural
hearing loss
o Chorioretinitis
and optic nerve
abnormalities
O Neurological
complications
 Miscellaneous

Congenital Eariy symptoms mayo Serological testso During any

Syphilis include: for syphilis stage of
o Skin rashes (VDRL and pregnancy when
(condyloma lata) FTA-ABS) the mother is
O Dark-field infected with
o Hepatosplenomegaly Syphilis
microscopy of
o Bone abnormalities lesions
(saber shins)
O PCR for
O Late-stage Treponema
complications can pallidum DNA
affect multiple
organs
Congenital HIV O Early symptoms are O petection of o During
(nfection often non-specific HIV-specific pregnancy,
o Chronic diarrhea, antibodies (lgG childbirth, or
oral thrush and lgM) in breastfeeding
o
Neurological neonatal blood when the
complications mother is HIV
o PCR for HIV
(encephalopathy. positive
RNA
seizures)
o Lymphadenopathy
and
hepatosplenomegaly
may be present
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 793

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97. Write in brief about the parasite schistoso ma haematobium. (3 marks)

Answer:

LIFE, CYCLE
O Involves three forms: adult worms, eggs, and larvae. This parasite has a two
host life cycle,with huans as the definitive host and freshwater Snails as the
intermediate host.
o Cercariae penetrate the skin, travel through dermal veins, enter the bloodstream,
and eventually reach the portal system.
o ln the portal system, they develop into adult worms.
o Adult worms migrate to the vesical and ureteric venous plexuses, where fertilization
occurs, leading to the production of eggs excreted in urine.
O The pre-patent period for the human cycle is about 3 months, during which eggs
appear in the urine.

Infective stage
Cercariae released from snail Diagnostic stage
Sporocyst in snail
and actively swim in water
A
with developing cercariae
4 Cercariae lose tails and
become schistosomulae
7

Skin 6
penetration Circulatlon 8

3 Miracidia penetrate
snall tissue Migrate to portal blood in
liver and mature
9

Eggs hatch,
releasing miracidia 10
Paired adult fluke migrate
to venous plexus of bladder
Egg excreted out along
the urine

Pathogenesis and clinical features

o Acute Schistosomiasis: Initial invasion of cercariae causes dermatitis at penetration
sites, leading to pruritic papular lesions.

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 Miscellaneous

o Chronic Schistosomiasis:
* Urogenital disease: Eggs deposited in the bladder mucosa lead to dysuria and
hematuria. Egg antigens cause delayed hypersensitivity reactions and granuloma
formation.
o Obstructive uropathies: Fibrosis from egg deposition can obstruct the ureters,
resulting in hydroureter and hydronephrosis.
* Bladder carcinoma: Metaplastic changes in the urinary mucosa may lead to
bladder cancer.
LABORATORY DIAGNOSIS
Urine Microscopy:
o Detecting terminal spined eggs in urine characterized by eliptical shape with a
sharp terminal spine.
o Histopathology: Demonstrating eggs in bladder mucosal biopsy or wet cervical
biopsy specimens in females.
o Antibody Detection: Tests for detecting serum antibodies against S. haematobium
adult worm microsomal antigen (HAMA).
o Antigen Detection: Detecting circulating antigen CCA and CAA in serum and
urine, indicating recent infection and treatment response.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 753
DO0

235 RMedEd
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8. Write in brief about Enterobius vermicularis. (3 marks)

Answer:
Life cycle:
o TranSmission: Infection occurs through:
Autoinfection
o Ingestion of Eggs
o Development in Man: The eggs typically contain fully developed larvae.
* After hatching in the cecum, larvae develop into adult worms.
s Gravid female worms migrate to the large intestine (rectum and colon) and lay
eggs on the perianal skin.
* Each adult female worm can lay up to 10,00O eggs per day.
* These eggs are embryonated and infective to humans, continuing the life cycle.
Pathogenicity and clinical Features:
o Cardinal symptoms include perianal pruritus (itching around the anus), especially
at night due to the nocturnal migration of female worms.
o Worms may be found in undergarments or buttock area.
o Scratching can lead to contaminated fingers and autoinfection.
o Abdominal pain and weight loss may occur in heavy infections.
o Other sites involved can include the urinary tract, peritoneal cavity, lungs, and
liver.
o Eosinophilia
Laboratory Diagnosis:
Microscopy of perianal skin samples is the preferred method to detect characteristic
eggs.
o Two collection methods are commonly used: cellophane tape and the NIH swab.
o Stool examination is generally not efective as the eggs are rarely found in the
rectum.
Characteristics of Enterobius vermicularis eggs:
* Planoconvex shape (one side convex, the other flat)
* Embryonated eggs contain a tadpole-shaped larva
* Non-bile -stained and colorless in saline mount
* Floats in a saturated salt solution.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 459
D00

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MIScellaneouS

q9. Write in brief about trypanosomiasis. (3 marks)

Answer:
o African Trypanosomes (Trypanosoma brucei complex): Transmitted
by tsetse flies,
they cause African sleeping sickness.
O American Trypanosomes (Trypanosoma cruzi): Responsible for Chagas' disease,
transmitted by the reduviid bug.
Trypanosoma
Life Cycle
Transmission Reduviid bugs defecate, and feces contact
abraded skin.
Human Cycle Trypomastigotes
Multiply
in blood.
Back to Trypomastigotes -
Amastigotes in tissues
Found

Vector Cycle (Reduviid Bug) Trypomastigotes Epimastigotes in gut

Metacyclic Trypomastigotes in hindgut
Excreted in feces.
Pathogenesis and clinical Features
Early Stage Disease Chagomas, Romana's sign (eyelid edema and
conjunctivitis).
Acute Chagas' Disase Symptoms like fever, hepatosplenomegaly,
and lymphadenopathy.
Indeterminate Stage Asymptomatic phase lasting for years.
Chronic Chagas' Disease Cardiac form (dilated cardiomyopathy,
rhythm disturbances, thromboembolism).
Gastrointestinal form (megaesophagus,
megacolon).
Laboratory Diagnosis Methods
1. Peripheral Blood Microscopy 2. Antigen Detection- ELISA

3. Culture(NNN medium) 4. Molecular Methods- PCR

5. Antibody Detection 6. Xenodiagnosis

Reference: Essentials of Medical Microbiology, Apurba s Sastry and Sandhya Bhat, 3rd
Edition, Page No. 366

237 MedEd
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MedEd FARRE: Microbiology

100. Write in brief about scabies disease. (3 marks)

Answer:
o Scabies, caused by the itch mite Sarcoptes scabiei, is transmitted through contact
with infested individuals or indirectly via shared items like clothing and bedding,
particularty in crowded conditions.
o Initial Infestation: asymptomatic for two months, during which transmission can
occur. In cases of reinfection, symptoms appear much sooner, typically within 1-4
days.
O Primary Infestation: The mites burrow into the upper skin layer but never below
the stratum corneum. This results in a rash, often found on the hands (especially
finger webs), wrists etc. Severe itching, particularly at night, is the most common
symptom, affecting various body areas, including those where mites are not visibly
detectable.
O Crusted (Norwegian) Scabies: This severe form occurs in immnocompromised
individuals, and involves the formation of vesicles and the development of thick
crusts over the skin. These crusts contain abundant mites but are associated with
only slight itehing.
o Secondary Bacterial lnfections can occur
Laboratory diagnosis:
o The laboratory diagnosis of scabies involves confirning clinical suspicions by isolating
mites or their eggs through skin scrapings, particularly in the finger webs and
wrist folds.
o Skin Scraping: Skin scrapings should be performed at the end of the burrows in
areas that are not inflamed or excoriated. The mineral oil helps mites adhere to
the blade, and the collected material can then be transferred to a glass slide.
o ldentification: Sarcoptes scabiei mites are very small and just visible to the naked
eye.
Treatment:
o The treatment of choice is pernethrin S% cream.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 824

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