FASTIDIOUS

ORGANISMS
• H A C E K ( H A E M O P H I L U S , A G G R E G AT E R ( A C T I N O B A C I L L U S ) , C A R D I O B A C T E R I U M ,
EIKENELLA, KINGELLA)
• RECOVERED FROM SPECIAL MEDIA : BRUCELLA, BORDETELLA, FRANCISELLA,
LEGIONELLA
• MICROAEROPHILES: CAMPYLOBACTER AND HELICOBACTER
 HAEMOPHILUS
• Mostly are normal flora of upper respiratory tract and oral cavity
• NM, Non spore forming, facultative anaerobes
• MOST PLEOMORPHIC BACTERIA (Coccobacilli)
• Most species are catalase and oxidase +
• Fastidious organism
• Preferred Incubation: 35-37C w/ 5-10% CO2 (capnophilic)
• Blood loving requiring blood factors: X and V
– X factor /Factor I/HEMIN : Heat stable from degradation of Hemoglobin
– V factor/ Factor II/ NAD: Heat labile from S. aureus, Neisseria, S.
pneumoniae, Yeast and Potato extract
• MEDIA:
– CHOC AGAR w/ X and V : inactivates NADases
– 5% Horse blood/Rabbit Blood agar
– SBA: NO GROWTH ‘’NOT SUITBALE’’ but when use needs NAD by
’’SATTELITISM” from organism producing NAD
• HAEMOPHILUS METHOD OF ID:
– HAEMOLYTIC REACTION ON HORSE BLOOD AGAR: If hemolytic or
Not
– GROWTH REQUIREMENT FOR X AND V FACTOR, D- TEST/
PORPHYRIN TEST
– CARBOHYDRATE FERMENTATION TEST
SPECIES X FACTOR V BETA- D-ALA CHO fermentation
FACTOR HEMOLY
SIS
H. influenzae + + - - Glucose
H. haemolyticus + + + - Glucose and Fructose (WEAK)
H. aegypticus + + - - Glucose
H. - + - + Glucose, Sucrose, Fructose
Parainfluenzae
H. - + + + Glucose, Sucrose, Fructose
parahaemolyticus
H. paraaprohilus - + - + G,S, F, LACTOSE
H. aprophilus - - - + G, S, F, LACTOSE
H. ducreyi + - - - GLUCOSE

1. D-ALA (D-AMINOLEVULINIC ACID)/PORPHYRIN TEST: detects ability of organism to convert D-ala to

porphyrin and Phorphobilinogen (when exposed to UV (+) red fluorescence)
2. CHO FERMENTATION TEST:
1. O/F HUGH LEIFSON TEST: pH indicator (Bromothymol Blue) +yellow (acid) and –blue/green
(alkaline)
2. CDC OF MEDIUM: pH indicator (phenol red) +yellow (acid) and –red (alkaline
 HAEMOPHILUS INFLUENZAE

• Aka Pfeifer’s bacillus

• Normal flora of respiratory tract
• Encapsulate strains are Pathogenic (ex. NTHi (Nontyphable H. influenzae)
• 6 serotypes : most common serotype: B (ENCAPSULATED associated w/
meningitis)
• VF: Capsule (POLYRIBOYSL RIBATOL CAPSULE) , IgA protease, LPS,
Pili and Fimbrae
• Hemolytic Pattern: Gamma
• Colonies w/ ‘’Dew Drops’’ appearance w/ MOUSY/ BASEMENT ODOR
on plate media
• Exhibits SATELLITISM “LUXURIANT GROWTH ’’ around the source of
V factor
• DISEASES:
– Causes MENINGITIS (serotype B) IN CHILDREN <5 years Old
– FLU bacteria secondary to virus
– EPIGLOTITTIS
– Bacterial Tracheitis
– Neonatal sepsi: serotype C
NTHib: otitis media w/ effusion (3rd most common), Conjuctuvitis
and sinusitis, Localized infection
 Haemophilus aegypticus
• Aka KOCH WEEK’s Bacillus
• Closely resembles H. influenzae biotype III
• Causes PINK EYE CONJUCTIVITIS
• Causes BRAZILLIAN PURPURIC FEVER on children
• Hard Chancre (Treponema pallidum) .Syphilis:
spirochetes
Haemophilus ducreyi
• Smallest Pathologic bacilli
• Needs ISOVITALEX incorporated in Media
• Forms the so called SCHOOL OF FISH/ FINGER
PRINT/ RAILROAD TRUCK APPERANCE
• Causes SOFT CHANCRE (Ulcerative Chancre) : painful
ulcers in genetalia
• Men: inguinal tenderness and Genital Lesions
• Women: Asymptomatic
 H. haemolyticus and H.
parahaemolyticus
• Normal flora of the upper respiratory
tract
• BAP: Beta hemolytic
• Mistaken as S. pyogenes (GAS)
H. parainfluenzae H. paraprophilus and aprophilus
• Rare infections • Normal flora of oral cavity found in
• Normal flora of upper respiratory dental Plaque (Gingival Scrapings)
tract • Endocarditis and Pneumoniae
• Mitral Valve: primary sites • Bone and Joint infections
• Foam loving
 HACEK: SUBACUTE BACTERIAL
ENDOCARDITIS
Aggregatibacter (actinobacillus)
A. aprophilus and A. paaprophilus
• Foam loving
• Dental plaques, bone and joint
infections
A. actinomycetamcomitans
• On plated media appears as STAR-
SHAPED colonies
• Usually isolated together w/ A.
israelli
• Cause Subacute Bacterial
Endocarditis (SBE) & Periodontitis
A. aprophilus
A. actinomycetamcomitans
C. hominis
E. corrodens
K. Kingae
Cardionbacterium hominis Eikenella corrodens Kingella
• ROSETTE arrangement/ Stick like • Fastidious organis, Capnophilic • Normal Flora of oropharynx
in yeast extracting w/ Pitting and requires Hemin • Affects Pediatric Population
• Infects Aortic Valve • Assacharolytic w/ yellow pigment
• Causes SBE w/ very large and sheres to tubes on broth w/ • Kingella kingae: Osteoarthritis <4
vegetation and no Fever granules years old
• PITS AND CORRODES the agar • K. denitrificans: SBE
after incubation
• w/ BLEACH-LIKE ODOR
• Causes the so called: HUMAN
BITE WOUND/ CLEANCHED
FIST WOUND: results from
trauma or fights
Catalase Indole LDC
- - -
+ - -
- + -
- - +
- - -
 GRAM NEGATIVE BACILLI RECOVERED
ON SPECIAL MEDIA:
BIOTERRORISM
A. BRUCELLA SPP
• Small coccobacilli (pleomorphic)
• NM, Strict Anaerobes, INTRACELLULAR
• Localized in tse riched in ERYTHRITOL (placental
tissuea and Bone marrow)
• Capnophilic (5-10% Co2)
• Catalase +, Oxidae +, Rapid Urease+ (PPM-B)
• Gamma hemolytic an Assacharolytic
• growth inhibited by Dyes
• Sensitive to Heat killed by PASTEURIZATION (56-60C
FOR 35 Minutes)
• CAUSES ABORTION IN ANIMALS
• AGENT OF BIOTERRORISM
• MOT: Ingestion of Unpasteured Milk, Inhalation of
organism and direct incouclation into blood stream
• Optimal Specimen: BLOOD (3-4 weeks)
• Media for Isolation:
• CASTANEDA MEDIA (BIPHASIC)
• TRYPTICASE SOY AGAR
• TRYPTOSE AGAR
• BRUCELLA BROTH AGAR/ WISCONSIN AGAR
• Serum agglutination test : GOLD STANDARD and
rapid test for Brucella
 B. abortus (aka B. mellitensis B. suis B. Canis
BANG’S
BACILLUS)
Animal Hosts Cattles Goat Pig/Swine/hog Dog
H2s production + + - +
Urease + in 2-24 hrs 2-24hrs 0-15mins 0-15 mins
Growth on media w/ + + - -
Biphasic Fuchsin
Growth on media w/ - + + +
thionine
Capnophilic + - - -

Note: B. melitensis, B. suis, B. canis: are H2S +

BRUCELLIOSIS:
Aka: emitting fever, undulant fever, Mediterranean fever, Maltese fever, Gibraltar fever, Crimean fever, goat fever,
and Bang disease.
 B. BORDETELLA SPP

• Strict aerobe, NM except B. bonchiseptica Causes WHOOPING COUGH

• INTRACELLULAR: replicates in ciliated respiratory Stages:
Epithelial cells 1. Catarrhal phase: 1-2 weeks (cold, fever, malaise)
• Virulence Factors: 2. Paroxysmal phase: 1-6 weeks (Whooping sound cough)
• Capsule 3. Covalescence: 2-3 weeks (Recovery)
• Adenylate cycles: Dec phagocytosis and NK cell • Optimal sample: Nasopharyngeal swab
formation • Donot use Cotoon swab : contains fatty acids
• Pertussin toxin: inc histamine release and secretion inhibits both Neisseria and Bordetella ( Calcium
of mucus , Dec chemotaxis alginate)
• Dermonecrotic: Necrosis of trachea and a strong • Media:
vasoconstrictor • BORDET GENGOU AGAR/ POTATO BLOOD
• Filamentous hemagglutinin: adhesion GLYCEROL
• LPS: irreversible shock and cardiovascular • Modified Jones Kendrick Charcoal
collapse • REGAN LOWE (enrichment and selective
media) : preferred media w/ horse blood, charcoal,
cephalexin, amopthericin B
 B. PERTUSSIS
• Bordet gengou bacillus resembles H. influenzae
• NM
• Produces MERCURY LIKE DROPLET COLONIES
• Causes WHOOPING COUGH/PERTUSSIS
• Ideal specimen: Nasopharyngeal swab /Saliine nasal
Wash
• PCR/Polymerase Chain Reaction: most sensitive for
diagnosis
B. Bronchiseptica B. Parapertussis
• Motile, Most active and can grow on conventional media Can cause pertussis like symptoms
• RAPID UREASE PRODUCERS (PPM-BBb)
• Rare cause of Respiratory disease

Urease Nitrate Motility Oxidase Citrate BAP

B. pertussis - - - - - -
B. parapertussis + - - - + +
B. Bronchispetica + + + + + +
 C. FRANCISELLA TULARENSIS
• Zoonotic
• Aerobic, NM, gram negative coccobacilli
• Enxhibit ‘’Faint Bipolar Staining’’,
• ALPHA hemolytic
• Cat+, Glucose, Mannitol and Mannose Fermenters
• Requires CYTSINE, AND THIOSULFATE for growth
• Causes TULAREMIA (aka Market Men dse,
Lemmings dse, Water Rat trapper dse, rabbit Fever,
deerly fever )
• MOT: Direct contact w/ blood and Animal/Vector Bite
or scratch)
• Media:
• BLOOD CYSTINE GLUCOSE AGAR (BCGA)
• Modified Charcoal Yeast Agar (MCYA)
• CAO w/ isovitaliex : bluish gray color w/ alpha
hemolysis
• CULTURE: BEST SENSITIVE TEST
• FORSHAY TEST : susveptibility test for Francisella
 LEGIONELLA
• Ubiquitous, naturally found in natural and artificial Optimal specimen: Bronchial Wash and Sputum
water Media:
• Cold loving (FOUND ON AIR • BUFFERED CHARCOAL YEAST EXTRACT
CONDITIONS/COOLING TOWER) (BCYE):
• Capnophilic and H2s+ • FEELEY GORMAN AGAR: borwn colonies
• Poor staining characterisitics • CUT GLASS COLONY appearance w/ IRIDESCENT
SHEEN

L. pneumophila • 15 serotypes
• Serotype 1: Legionnaire’s
dse/Broad Street
pneumonia/PONTIAC FEVER
• Serotype 6: pneumoniae
L. micdadei Pitsburgh pneumonia

L. bozemanii Wiga’s agent of pneumonia

 MICROAEROPHILES : REQUIRES REDUCED AMOUNT
OF O2 (5%) , CO2 (5%0 NITROGEN (85%)

A. HELICOBACTER PYLORI
• Formerly Campylobacter coli
• Habitat: Human gastric
mucosa/pyloric end of stomach
• w/ 4-6 polar flagella
• VF: very strong Urease activity
(MAKES ph alkaline) (PPM-BBbH)
• Causes:
• TYPE B GASTRITIS
• PEPTIC ULCER/ GASTRIC
ULCER/DOUDENAL ULCER
• GASTRIC CARCINOMA
Spxmn: tse biopsy/autopsy
Media:
• CAMPY-BAP (BAP w/ Vancomycin,
trimetrophim, Polymixin B)
• Brucella agar w/ 5% sheep blood
• CAP
• Modified Thayer Martin Media
• Stuart Media: Transport media
(stool)
 DIAGNOSIS FOR H. PYLORI INFECTION
TESTS ECCUT

1. Invasive, Nonculture, costly but diagnostic and

Endoscopy therapeutic

2. Copro Kit like tests using Immunochromatographic principle

Stool
Antigen
Test

3. Culture Seldom used

4. Urea • Gold standard

Breath • Non invasive, Nonculture
tests • MEASURES UREASE ACTIVITY

5. TISSUE For gastric carcinoma

BIOPSY Stained using WARTIN-STARRY STAIN
 B. CAMPYLOBACTER
• May appear like V. cholorae Spxmen: BLOOD
• Zoonotic : Abortion on animals • Media
• Grows at 42C • CAMPY-BAP : brucella agar w/ 10%Sheep blood,
• Appears as S-shaped bacilli/ WINGS OF Vancomycin, trimetrophim, Poly B, Amp B,
SEAGULLS Cephalotin)
• Motile w/ SINGLE POLAR FLAGELLUM W. • CAMPY-CVA : brucella agar w/ 10%Sheep blood,
DARTING MOTILITY cephalotin, Vancomycin, Amp B0
• Modified SKIRROW: BAP w/ 7% Horse Blood
lysed, Vancomycin, Trimetrophim, Poly B
• Modified Charcoal Cefoperazone Deozycholate
Agar

CAMPLYLOBACTER JEJUNI
• Associated w/ gastritis and diarrhea
• MOT: handling infected pets and STD (Ssexually transmitted disease)
• GUILLAIN-BARRE SYNDROME
• Autoimmune acute paralysis w/ gastritis and diarrhea
• Stools w/ segmented Neutrophils and RBCs
• Initial signs: CRAMPS AND BLOODY DIARRHEA
Campylobacter jejuni
• Grows at 4c
• Cat and Oxidase +
• Nitrate +
• Cephalotin 30 ug Resistant
• Nalidixic acid Sensitive
• HYPPURATE HYDROLYSIS +
• Assacharolytic
Helicobacter pylori
• Grows at 4c
• Cat and Oxidase +
• Nitrate VARIABLE
• Cephalotin 30 ug SENSITIVE
• Nalidixic acid RESISTANT
• UREASE +
• Assacharolytic
 NON FERMENTERS
• OBLIGATE AEROBES • Motile (polar Flagella & petrichous(alcaligens)
• NOT A NORMAL FLORA Except B. mallei , Acinetobacter,
• Ubiquitous found in MOIST ENVIRONMENT Flavobacterium
SUCH AS IN HOSPITAL • Oxidase +/ Oxidizers except Alcaligens O-
• Causes NOSOCOMIAL INFECTION (variable)/F-
• Non CHO fermenters/assacharolytic
• TSI: K/K
 A. PSEUDOMONACEAE
RNA group 1 RNA group 2 RNA group 4
• P. pseudomallei • P. diminuta
Flourescent Stutzeri group Alcaligens
• P. cepacia • P. vesicularis
Group
• P. gladioli • P. paucimobili
• P. aeruginosa • P. stutzeri • P. alacaligens • S. putrefaciens
• P. • P. mendocina • Pseudoalcali
fluorescence • CDC group gens
• P. putidia VB3 • Pseudomona
s species
group 1
 1. P. AERUGINOSA
• Most frequently isolated non-fermenter (in ICU)
• TSI: K/K
• Grows well at 37C-42C
• Oxidase + and Beta hemolytic in BAP
• MHA: GREEN METALLIC SHEEN
• Colony Odor: OVERRIPE GRAPE/ CORN
TORTILLIA LIKE ODOR: due to release of 2-
aminoacetaphenune
• Virulence Factors:
• Exotoxin A : blocks protein synthesis
• ALGINATE CAPSULE :prevents phagocytosis
• Produces pigments: Pyocyanin (Blue), Pyoverdin
(green), Pyorubin (red), Pyomelanin (black)
• Causes Mild Otitis externa : Swimmer’s ear,
Jacuzzi/Hot Tub syndrome, Erythema
gangrenosum/blue skin lesions, Keratitis
• May cause severe wound infections in BURN Px, UTI,
pneumonia and sepsis
• CITRATE AND ACETAMIDE UTILIZATION
TEST+:
• pH indicator (bromothymol blue)
• +: blue -: green
• Grows on CETRIMIDE AGAR
P. flourescence and P. putida P. stutzeri and P. mendocina
Motile Oxidase + Soil Denitrifiers
Pyocyanin negative and Pyoverdin positive Able to release and reduce nitrogen in soil and return it to
atmosphers

P. aeruginosa P. fluorescens P. putida

pyocyanin + - -
Pyoverdin + + +
Growth at 42 C + - -
Acetamide + - -
Gelatin hydrolysis + + -
Nitrate reduction + - -
 P. alcaligenes P. P. denitrificans
pseudoalcaligens
Oxidase + + +
Nitrate to nitrite V + +
Argine decar V V +
Lysine Decar - - -
Glucose + - +
Lactose - - +
Mannitol + - -
B. cepacia
B. BURKHOLDERIA
• Previous names (P. kinaii/ P. multivorans)
• Found near water sources
• On Plated media: DIRT LIKE ODOR w/
yellow/ green pigment w/ polar tuft flagella
• Causes:
• ONION BULB ROT/ FOOT ROT IN
MAN
• CYSTIC FIBROSIS (P. aeruginosa) ;
chronic granulomatous dse
• CF: Sweat (Chloride and Sodium)
B. gladiola
• Plant pathogen
• Human: same w/ Cystic Fibrosis and Chronic Granulomatous disease in px w/ Lung transplant
B. mallei
• Aka Glander’s bacillus
• Can be an agent of bioterrorism
• Causes: GLANDER’S DSE/ FARCY DSE
• Dse of animals like horse
• MOT: direct contact thru skin
abrasions and Inhalation of organism
B. pseudomallei
• Aka Whitmore’s bacillus
• EARTHY LIKE ODOR ON ASHDOWN
MEDIA
• Causes: MELLOIDOSIS/ VIETNAM
TIME BOMB
• Glander’s like dse characterized by
severe pneumonia and necrosis of
skin
C. STENOTROPHOMONAS
• May cause nosocomial infection like pneumonia and UTI
• Large colonies w/ yellow pigmentation in TSA, Lavander green pigment and Blue in Mac Conkey

B. cepacia B. pseudomallei S. maltophila

Oxidase Weak + + -
Nitrate to nitrite V + V
Arginine - + -
Lysine + - Slow+
Glucose + + Weak +
Lactose + + Strong +
Mannitol + + -
 D. ACINETOBACTER
• Colonizes Moist areas of skin
• 2nd most common Nonfermenters
• NM, Cat+, Oxidase –
• Grows well on BAP (GUMMY ALPHA COLONIES) and MAC (PURPLUSH HUE)
Acinetobacter baumanni Acinetobacter Lwoffi
More virulent Asaccharolytic
Confused w/ Neisseria and Morxaella (Cat + and Ox
+)
Glucose oxidizers but not fermenters
 OTHER NON FERMENTERS
Alcaligens faecalis
• O-/F-/ Assacharolytic
• OXIDASE VARIBALE and Cat +
• Motile (Peritrichous) and uses citrate
as Carbon source
• “SWEET ODOR/ FRESH APPLE’
Flavobacterium meningosepticum Moraxella catarrhalis
• Yellow pigment SUSCEPTIBLE TP PENICLLIN
• Neonatal meningitis, septicemia, and -unsual for Non-fermenters
Endocarditis
• Motile, Oxidase+, Glucose/ Dextrose
oxidizers

Moraxella Lacunata Psychrobacter Immobilis Oligenella

• Aka Morax Axenfeld bacillus /
Haemophilus duplex
• Produce ‘’lacunate’’: pitting of Agar
• Agent of Blepharo conjunctivitis
• Same with Moraxella Gram neg • UTI
Oxidse – diplococci but not • Oxidase + and PPD +
susceptible to penicillin • Nitrate +
• Isolated from eye of Newborns • Gas+
• ‘’ODOR OF ROSES’’: like phenyl
ethyl alcohol

Note: Grows on Modified Thayer Martin Media PPM-BBbH: Rapid urease producers
• Brucella, H. pylori, Kingella, P. immobilis Proteus, Providencia, Morganella, Brucella, Bordetella
brochoseptia, H. pylori
•
FAMILY VIBRIONACEAE
Normally found on Sea water (MOT: eating seafoods)
• Gram Negative Curved, Comma, Straight bacilli
• Facultative anaerobes
• Motile (monotrichous) w/ ‘’Shooting star motility
• Halophilic except V. cholorae and V. mimicus (0-3% NaCl)
• Positive string test ( 0.5 Na deoxycholate): Vibrio spp
• Spxmn: Stool/ Rectal swab
• Cary Blaire: transport media
• Avoid Buffered Glycerol Saline as transport media : toxic
to Vibrio and C. diptheriae
• Media:
• TCBS (Thiosulfate Cirate Bile salt Sucrose agar) (selective
& differential) :
• CHO: Sucrose
• pH indicator: Bromothymol zblue
• + (yellow): V. cholorae and V. alginolyticus
• -Green : V. parahemolyticus, V. vulnificus, V. mimicus
• APW (Alkaline Peptone Water) : enrichment broth (1%
NaCl pH. 8.5)
• SBA/ CAP w/ 0.5 % NaCl: ‘’Indescent w/ Greenish Hue’’
• MAC Conkey agar: NLF except V. vulnificus

3 GENERA
• VIBRIO SPECIES
• AEROMONAS
• PLESIOMONAS (NOW AN
ENTEROBACTERIACEAE)
 VIRULENCE PRESUMPTIVE
FACTORS IDENTIFICATION
1.O AND H -on cell wall and Tests Use to differentiate
ANTIGENS Flagella respectively 1. APW, TCBS +, To differentiate Vibrio
2. Choleranogen/ Heat Labile Stringtest, Vibriostatic from Plesiomonas, and
Cholera toxin Agent (0/129 (150 ug) Aeromonas
3. Heat Stable Lysin -Lyse RBC 2. Cat +, Ox +, Nitrate + Vs Enterobacteriaceae
–V. parahaemolyticus (ex. V. metchinicovii) (Cat+, OX -, Nitrate +)
-Kanagawa 3. Inositol fermentation Plesiomonas +
Phenomenon LOA decarboxylation
4. CHO fermentation • All glucose fermenters
• Lactose: V. vulnificus
• Sucrose: CLassic, Eltor,
V. alginolyticus
• Inositol: Plesiomonas
VIBRIO SPP
FLOW CHART ID
 VIBRIO CHOLORAE
• Non Halophilic (w/ V. mimicu) Causes CHOLERA
• String test + (Na Deoxycholate) • Diarrhea w/ RICE WATERY STOOL
• +cholera red test (Non specific) (Epithelial Cells and Vibrio)
• APW w/ Tryptophan and Nitrate + • Choleragen causes
organism > incubate + sulfuric acid • Massive Fluid Loss
• +: red due to Nitrosoindole • Dehydration
• Loss of Electrolytes (Na)
 V. CHOLORAE SEROT YPES/
BIOT YPES
V. Cholorae 01 & 0139 V. Vholorae atypical/ V. Cholorae Non 01 Classical El tor
Non toxigenic 01
Hemolysis of - +
• Causes classical • Biochemically similar • Causes Non-epidemic
epidemic cholera w/ 01 but choleragen diarrhea
sheep RBC
• 0139 (pandemic VP test - +
strain): cross ract w/
Aeromonas antigens Chicken RBC - +
• 2 biotypes: Classic agglutination
and Eltor
Polymyxin S R
Susceptibility and
Vibriostatic Agent

V. CH OLOR A E SER OT YP ES: USED FOL LOW PA ND EM ICS

( BA SED ON O A NT I G ENS ON CE L L WA L L )
Serotypes Pandemics in O antigen O antisera I antisera Phage types
Ogawa/ Variant India AB + - • Mukerjee Group IV
F
Inaba/ original Philippines AC - +
J
Hikojima/ Japan ABC + +
Middle/
Intermediate
 OTHER VIBRIO
Species Disease Other infos TCBS NaCl

V. Parahaemolyticus • Gastroenteritis due to • ‘’KANAGAWA green 1-8 %

(2nd most common) contam Seafood PHENOMENON’’: heat
(Japan 1st case) • ‘’SUMMER DIARRHEA” stable lysin lyse RBC
• 03:K6 : PANDEMIC • ‘’WAGATSUMA AGAR
STRAINS +’’
• High salt mannitol
medium
V. Vulnificus • Wound infection • LACTOSE green halophilic
(2nd most serious • Septicemia FERMENTERS IN MC
type of vibrio) • Liver dysfunction • Mot: eating SHELL FISH
(MOST • Inc serum iron (RAW OYSTERS)
VIRULENT) • Necrotizing Fascitis
V. Alginolyticus • Wound, ear, eye, burn OCCUPATIONAL HAZARD Yellow 1-10%
(Least pathogenic) infection
• Otitis externa
• occupational hazards for
Fishermen and Tailors
V. mimicus Gastroenteritis and ear Green Non halophilic
infection
V. Fluvialis and V. Diarrheal Yellow Halophilic
furnissil
 AEROMONAS
• Ubiquitous (fresh water, Estuarine, marine) • Media
• Mesophilic (37C) Motile : A. caviae (most common • SBA: Mucoid and Beta hemolytic
isolate) • Mac/ SSA/ EMB: LF pink
• Psychrophilic (22C) Nonmotile: A. salmoniada • CIN II: along w/ Y. entercolitica
• Disease associated: • APW:
• Wound and Cellulitis infection
• ACUTE CHOLERA LIKE:
• HUS and Kidney disease
• Infxn on px w/ transplanted kidney
• Necrotizing fasciitis

Species Infos
A. caviae (most Pediatric diarrhea
common)
A. Veronii biovar sabria Leech Therapy cases
A. Hydrophila Water loving bacteria (aquatic environment)
Cuses GIT disease and Cutaeneous infection
 PLESIOMONAS
• Salt water environment
P. Shegilloides (most common isolate)
• Resides on warm and cold blooded animals • May cause gastritis
• Contains O and H antigen (may cross react with • Now belongs in Enterobacteriaceae but are OX +
shigella ) • ONLY BACTERIA POSITIVE IN THREE
Decarboxylation) Lysine, Ornithine, Arginine
decarboxylase
Vibrio spp Aeromonas Plesiomonas

• Gram neg curved, comma, straight Gram Neg straight Gram neg straight singly/pairs/ chains/
• TCBS AND STRING TEST + Non halophilic filamentous
• Vibro 0129 (150ug) Sensitive Halophilic
• O % NaCL: V. cholorae and mimicus
• 6.5% NaCl >: other vibrio

Oxidase + Oxidase + Oxidase +

Gelatin + Gelatin, DNAse, SPOT indole + Glucose and Inositol Fermenters
Glucose fermenters Glucose and Lactose fermenters Lysine, Ornithine, Arginine
Lysine and Ornithine Decar Lysine and Arginine Decar Decarboxylase
 MISCELLANOUS ORGANISM
PASTEURELLA
• Zoonotic
• Cattles: Shipping fever (Hemorrhagic
septicemia)
• Human: ANIMAL BITE WOUND
• Musty/ Mushroom Odor
• Capsulates: Hyaluronic Acid
• Gram staining: Neg w/ BIPOLAR STAINING
‘’Safety pin appearance’’
• Ferment glucose w/ Moderate Acid w/o gas
Gardnerella vaginallis
• Previosly Corynebacterium/ Haemphilus vaginalis
• NF of Urogenital
• Gram Varibale/ Neg bacilli
• Casues BACTERIAL VAGINOSIS
• Arnel’s and Nugent Clinical Criteria for diagnosis:
• FOUL smelling Gray Milky vaginal discharge
• Cytology/ Paps smear: look for CLUE cells
(Squamous epithelial cells w/ G. vaginalis)
• WHIFF TESt/SNIFF test: add KOH to vaginal
discharge = FISHY AMINE ODOR
• pH vaginal fluid: >4.5
• Isolation using HBT (Human Blood Bilayer
Tween)
Capnocytophaga gingivalis
• Capnophilic
• NF of Human cavity
• Fusiform/pointed ends
• SLIDING/ GLIDING MOTILITY
• Causes Oral ulcers
Chromobacterium violaceum
• Not a normal flora found in
environment
• DNAse Agar: Violet pigment
(VIOLACEIN)
• BAP: Beta hemolytic w/
AMMONIUM CYANIDE ODOR
• Associted to px w/ neutrophil deficit
and Chronic Granulomatous disease
Streptobaccilus monilliformis
• On Broth: Puff of balls
• String of Pearl Appearance
• RAT BITE FEVER: animal bite/
scractch
• HAVER HILL FEVER: Contam
unpasteurized Milk
 SPIROCHETES
• Gram Negative, Slender, Flexous HELICALLY MICROSCOPE FOR VISIBILITY
SHAPED, unicellular bacteria w/ one or more complex Borrelia Treponema Leptospira
turns in helix
• Motile: Flexible cell wall w/ fibrils Bright field Darkfield Dark field
• PERIPLASMIC FLAGELLA/ AXIAL Phase Contrasts
FILAMENTS Fluorescence
• Cockscrew (Lashing, Extension, Flexion) Motility
• 0.1-.05 um wide and 5-20 um long STAINS FOR SPIROCHETES
• Reproduction: • Levaditi’s stain and Treponemal stain
• TREPONEMA : by Transverse Binary fission • For Tissues:
• LEPTOSPIRA & BORRELIA: by Binary fission • Wartin’s Starry
• Modified Stainer-Stainer
• Silver Nitrate 10% (Fontana TribonTeau stain)
LEPTOSPIRA
• 0.1 um BY 5-15 um
• Zoonotic (Fogs/ Mouse urine)
• Present in water and mud enter thru
breaks in the skin not on intact
mucisa/skin
• Obligate aerobes
• Multiply by Binary Fission
• 2 periplasmic (axial) flagella
• Tightly coiled w/ 1 or both ends bent
to form hook ends
• Visible in darkfield, Phase contrasts,
Flouresecent microscope
• Cant be stain but can be impregnated
with silver nitrate
Culture media
• FLETCHER’S semisolid Media
• Stuart Liquid
• EMJH (Ellinghausen Mc Cullough
Johnson)
BORELLIA
• 0.2-0.5 um by 3-20 um
• Arthropod Bourne (Ticks and Louse)
• Blood spirochetes
• Mostly obligate anaerobes and some
aerotolerant
• Multiply by Binary fission
• 15-20 periplasmic flagella
• 3-10 spiral less tightly coiled (loosely
coiled)
• Visible in brightfield Microscope
• Can be stained easily
Culture media
• KELLY medium: 33C for 6 weeks
• Barber Stoenner
TREPONEMA
• 0.1-02 um by 6-20 um
• Normal microbiota and prominent in
oral cavity
• MOT: STD, Blood transfusion,
Transplacental
• Anerobic
• Multiply by Transverse Binary fission
• 3 periplasmic flagella
• 4-14 spirals w/ pointed ends
• Visible w/ darkfield microscope
• Cant be stain but can be impregnated
with silver nitrate
Tests:
• Non treponemal tests (screening test)
VDRL and RPR test
• Treponemal tets (confirmatory)
FTA-ABS , TP-PA test, MHA, TPI,
EIA test
 TREPONEMA
1. TREPONEMA PALLIDUM
• Causative agent of SYPHILIS aka
• HARD CHANCRE/ FRECNH POX/ GREAT
POX/ EAGLE POX
• Great imitator (part of TORCHES): crosses
placenta and infects infants (Teratogenic)
• T. gondii, Rubella, CMV, HSV, Syphilis
• MOT: Sexually transmitted, Blood Transfusion,
Transplacetal
• Non culturable but can be maintained using
TESTICULAR CHANCRE OF RABBIT
• Drug of choice: PENICILLIN
• Can cause Herxheimer reaction: release of LPS
endotoxin (Lipid A) due to Antibiotic
 • Diagnosis of syphilis
• SEROLOGY (TREPONEMAL AND NONTREPONEMAL TESTS)
• Seroud Transudates

STAGES
• Non culturable in vitro but can be maintain alive in Testicular chancre of
rabbits
PRIMARY SYPHILIS 2NDARY SYPHILIS Latent syphilis Tertiray Syphilis CONGENITAL
(6 WEEKS) (6 WEEKS) (6 years)
• HARD CHANCRE/ • ’’CONDYLOMATA LATA • Absent symptoms but • ‘’GUMMAS’’ • Structural defects but not
HUNTERIAN CHANCRE • Lesions outside Genitals SEROLOGICALLY + • Lesions on deep organs of intellectual; defects
• Genital lesions • Rash on Palms and soles bodies
• NO systemic signs and • Granulomatous lesions
symptoms • NEUROSYPHULIS
• Dx: motile treponemes • AORTITIS
 3 SUBSPECIES OF T. PALIIDUM THAT CAUSES NON-VENEREAL
DISEASE (NON STD ONLY CONTACT WITH LESIONS)
Subspecies Disease infos
T. Pallidum subs. pertenue YAWS/ FRAMBESIA • Affects Skin and Bone
• Same with syphilis but with elevated lesions and granulomatous
nodules
T. Pallidum subs. carateum PINTA • Painless (papules) lesion
• Erythematous rash that hyperpigment in time
• Found in tropical regions

T. Pallidum subs. Endemicum BEJEL/ • Resembles yaws with primary and secondary papules
ENDEMICUM • MOT: contam Utensils
syphilis • Hot areas of the world

Others:
• T. cuniculi: venereal spirochetosis
• T. vincentil: Trech Mouth/ Vincent stomatitis
 LEPTOSPIRA
I. LEPTOSPIRA INTERROGANS
• Pathogenic Diagnosis:
• VF: Surface Antigens, Soluble Hemolysin, Endotoxin
• Incubation: 10-12 days • 1st week: Blood and CSF (Inc IgM)
• MOT: Direct Contact w/ animal urine • Afetr 1 weeks: urine (Inc IgG)
• Causes ‘’HUMAN AND ANIMAL LEPTOSPIROSIS
• Influenza like signs • Rapid test: Macroscopic Slide Agglutination
2 phase • Gold Standard: MICROSCOPIC
1. Anicteric: septicemia, High Fever and Headache
2. Ecteric: Kidney, Liver cells (WEIL’S DISEASE): Severe form of the
AGGLUTINATION
dse
3. Note: aseptic meningitis: HALL MARK OF IMMUNE RESPONSE

L. biflexa: Non pathogenic found on water and soil

BORELLIA
1. BORELLIA BURDORFERI
• Agent of LYME DISEASE (TICK BORN Stages:
RELAPSING FEVER) 1. BULL’S EYE RASH (Erythema Chronisum
• Ticks: IXODES DAMMINI/ DEER TICKS/ Migrans) at the bite site
BLACK LEG TICKS) 2. Mutiple smaller ECM dessiminated thru blood
• VF: ability to bind plasminogen and Binding may affect bones, heart, and liver
factor A 3. Neurologic Abnormalities , cardiac,
• Drug of choice: DOXYCYCLINE AND Musculoskeletal, Arthritis
AMOXICILLIN
 2. BORRELIA RECURRENTIS
• Causes LOUSE BOURNE RELAPSING
FEVER/ FAMINE FEVER/ EPIDEMIC
RELAPSING FEVER
• Louse: PEDICULUS HUMANUS
• Incubation: 2-5 days and last 3-7 days
• Sample: Giemsa/Wright Blood smears
B. duttoni, B. parkeri, B. hermsii
• Causes ENDEMIC RELAPSING FEVER
• Ticks: ORNITHODOROUS / SOFT TICKS
VF:
• Surface AG: ‘’ ANTIGENIC SHIFT’’
• C4b Binding protein and Factor H: evades
complement
• Treatemtent: TETRACYCLINE ‘’ Jarisch
Herxheimer reaction
INTRACELULLAR ORGANISMS

• CHLAMYDIA SPECIES
• MYCOPLASMA SPECIES
• RICKETSIALES
 CLAMYDIACEAE
 Gram negative (if peformed) • CANT BE CULTURED IN PLATED MEDIA but can be
 Has both DNA and RNA maintained on Viral culture medis (CELLS)
 Obligate intrecelullar parasites • Cytological examination: For inclusion bodies
 Primay host cell (NONCILATED COLUMNAR OR determination
TRANSITIONAL EPITHELIAL CELLS) • Papanicolaou stains (for endocervical specimens)
 Has peptidoglycan on cell wall • Iodine stains: Half Moon shaped
 Sensitive to antimicrobial agent
 Sensitive to interferon
 Mutilphy by binary fission

 2 distinct forms in GROWTH CYCLE:  LPS (LIPOPOLYSACCHARIDE)

 RETICULATE BODIES: non infectious/ REPRODUCTIVE
FORM
 w/ Ketodeoxyoctonate shared by most members
 ELEMENTARY BODIES: INFECTIOUS and has outer membrane of family
similar to gram – bacteria  Primary antigen detected by genus-specific tests
 2 cells wall components: and serologic assays
 MAJOR OUTER MEMBRANE PROTEIN (MOMP)
 Most prominent components  FLOURESECENT-LABELED MONOCLONAL
 A transmembrane proteins ANTIBODIES: to detect chlamydial inclusions
 Contains both:  Species-specific monoclonal antibodies: binds to
 Species-specific epitopes
 Subspecis-specific epitopes define by Monoclonal
MOMP
Antibodies  Family-specific antibodies: binds to LPS
 SPECIMEN HANDLING AND PROCESSING
Specimen and Direct Microscopic Cell Culture Non-Culture , Non- Antibody Detection
processing Exam amplified
• C. trachomatis CYTOLOGIC -was considered Gold • Direct Fluorescent • Complement
• Should contain METHODS: standard until PCR Assay (DFA) : Fixation (CF):
infented -involves Trachoma and endocervical and detects family
Epithelial cells Inclusion Conjuctivitis Cell lines for culturing: Urethral specimen reactive antibody
• 1st void urine -for immediate quality • Mc Coy cells • Enzyme • Microimmunofluores
and vaginal control of specimen • Hep 2 cells Immunoassay (EIA): cence assay (MIF)
swab (not whether columnar • Hela cells detects LPS/MOMP • Method of
transudates) epithelial cells are • Buffalo Green but do not use for choice for
• C. pneumoniae present Monkey Kidney urine or vaginal antibody
• Sputum, swab detection for C.
bronchial & trachomatis
throat swab
Swabs: Dacron, Cotton, Non-Cultured,
Calcium alginate AMPLIFIED:
-w/ plastic/ metal shafts -PCR (NEW GOLD
not wooden (toxic to STANDARD)
chlamydia) -NAATS: preferred
 CHAMYDIA TRACHOMATIS
TRACHOMA W/ INCLUSION
CONJUCTIVITIS (TRIC)
• Aka endemic trachoma
• Chronic eye infection
• Number 1 cause of preventable
blindness in world
• Route: Hand-Eye fomites
• Serotype: A, B, Ba and C
• Spxmn: conjunctival scrapings
• TreatmentL surgical procedures
LYMPHOGRANULOMA
VENEREUM (LGV)
• Sexually Transmitted Dse
• Pxs have Inguinal and Rectal
symptoms
• Causes: BUBO FORMATION
• Rupture of lymphnodes
• Linked to Parinaud
Oculograndular
Conjuctivitis
Note: NONGONOCCOCAL URETHRITIS
-by C. trachomatis, M. homonis, U. urealycatum
-Non purulent
-affects males <60 years old (w/ no history of kidney dse/ prostatis)
-Gram staining: <WBCs/ HPF
+ Leukocyte Esterase
UROGENITAL DISEASES INFECTIONS OF NEWBORN
MEN: • Nasopharyngeal infnxs
• Nongonococcla urethritis • Pneumoniae
(NGU) • IgM by MILF (method of
• Epididymitis choice )
• Prostatitis • CONJUCTIVITIS
WOMEN: • INCUBATION: 4-5 days
• Edematious eye lids
• Urethritis
• Copious yellow disachrage
• Follicular cervicitis • Corneal panus formation and
• Salphingitis (result to scarring of conjunctiva
ectopic pregnancy and • Treatment:
sterility) ERYTHROMYCIN
• Pelvic Inflammatory dse
(PID)
• Reiter syndrome
 LAB DIAGNOSIS
• Specimen should consists of infected Epithelial cells
• First void urine and vaginal swab is excellent
• Swabs should not have a shaft made of woods

TESTS INFOS
CELL CULTURE Was considered Gold standard
PCR (Polymerase Chain Reaction) New Gold standard
NAATS Preferred diagnostic method (but not for conjunctival, oropharynx, and
Rectal specimens)
EIA (Enzyme Immunoassays) Most common rapid Antigen detection assay
MICROIMMUNOFLUORESECEN Method of choice for detecting antoibody
CE ASSAY
C. pneumoniae C. psitacci
• TWAR STRAIN (Taiwan Acute Respiratory Strain) • ORNITHOSIS OR PARROT FEVER
• Human is only known hots • MOT: dropping inhalation aerosol
• Grows poorly in cell cultures
• Factor for ASTHMA, Cardiovascualr dse, Guillain-Barre Syndrome (3 rd most common
cause of infectious respiratory disease)
• Lab diagnosis: MIF assay (method of choice) • Lab diagnosis: is dangerous and not recommended
• IgM titer (>1:32) and IgG titer (>1:512) : current penumoniae infections • Ruling out: Immunoassay and PCR
• IgG titer: >1;16 but < 1:512 : past infections

C. trachomatis C. penumoniae C. Psittaci

Inclusion Morphology Round, Vacoular Round, dense Variable shape, dense
Elementary bodies Round Pear-Shpaed Round
Morphology
Glycogen inclusions + - -
Sulfadrug S R R
DNA relatedness 10% 100% 10%
against C.pneumoniae
Natural Hosts Humans Human Birds
Major human Dse TRIC and LGV TWAR (pneumonia, Ornithosis
Pharyngitis , (peumoniae)
Bronchitis)
Number of serovars 20 1 10
 MYCOPLASMA
 Smallest free living organisms found in several ani,als • Originally called PPLO (PLEURO PNEUMONIA
and plants and requires STEROL (in plasma LIKE ORGANISM) (DINES STAIN NOT GRAM
membrane) for growth STAIN)
 Pleomorphic and Lacks cell wall (FRIED EGG • Culturable in artificial media (Embryo of Check cells) :
APPEARANCE) forms tiny comonies w/ Fried egg appearance
 Resistant to PENICILLIN (since it lacks cell wall which
Beta-Lactams is against)

M. Pneumoniae GENITAL MYCOPLASMA

• Formerly known as EATON agent • Mycoplasma hominis (STD/ Nongonococcal urethritis)
• Causes PRIMARY ATYPICAL PNEUMONIAE/ • Ureaplasma urealyticum
WALKING PNEUMONIA • Nongonoccocal urethritis in males and post partium
fever in females (Sexual Contact)

GLucose Arginine Urease

M. hominis - + -
M. pneumoniae + - -
U. urealyticum - - +
 ORDER RICKETSIALES
FAMILY RICKETTSIACEAE FAMILY ANAPLASMATACEAE
GENUS GENUS
 RICKETTSIA  ERLICHIA
 ORIENTIA  ANAPLASMA
 COWDRIA
 NEORICKETSIA
 WOLBACHIA
Grows on HOST’s CYTOPLASM AND NECLEUS Grows in PHAGOSOME OF HOST’S WBC
OF ENDOTHELIAL CELLS

OTHER
GENUS
COXIELLA Not transmitted by arthrobpods
Grows in PHAGOLYSOSOMES
Spore formers and can live in acidic environment
BARTONELLA Infects RBC’S
 ORDER RICKETSIALES
 NON MOTILE w/ Both DNA and RNA 2 ways on how they persist in nature by arthropod Hosts:
 Obligate intracellular pathogens • By Transvarial Transmission
 Arthropod Bourne except Coxiella • Rickettsia is passed thru generation of arthropods
 MANIFESTED SYMPTOMS: (can be both vectors and reservoir)
 FEVER AND HEADACHE • Arthropods directly inoculate new Hosts w/ ricketssia
 RASHES except Q fever and Erhlich disease during feeding
 Giemsa stain: Blue • Arthropod vector die of rickettsial infection and
 Machiavello stain: Red animals/human act as natural reservoir except
 Gimenez stain: Reddish Black Ricketssia prowazekii

Notes:

 Isolation of ricketssia is not recommended because of • Serologic Assay: Only Lab tests performed for diagnosis
their infectious nature but only for convalescent specimens
 Require BSC III • Immunoflourescence Antibody tests (IFA): Gold
 Immunohistochemical Detection: established Method standard for Antibody Detection
for detection • WEIL-FELIX tests: uses Antigens from Proteus species
because it cross react w/ ricketsial antigen
• X19 and OX2 strains of Proteus vulgaris
• OXK strains of Proteus mirabilis.
 A. SPOTTED FEVER GROUP
• Replicates in cytoplasm and nucleus epithelial cells
• Tick Bourne except R. akari (CAT FLEA)
SPECIES DSE MOT/ VECTOR
R. rickettsiae Rocky Mountain Spotted Ticks (Permacenter
Fever (Most severe) varibalis)
R. conorii Boutounneuse fever/ Ticks
Meditteranean spotted
feve/ Indian Tick typhus/
Kenya Tick fever/ South
African Fever
R. sibirica North Asian Tick typhus Ticks
fever
R. Akari Rickettsial Pox Mitebite/ Chigger from
House mouse
 TRANSITIONAL GROUP
Species Disease MOT/ Vector
Cat Flea Rickettsia / R. feleus Murine Typhus like illness Flea bites/ Feces
R. australis Quuensland Tick typhus fever/ Tick bite
Australian
Rickettsia japonica Oriental spotted fever Tick bites

TYPHUS FEVER GROUP

• Replicates in Cytoplasm nad causes HOST CELL LYSIS
• (MOT: defacates and scratch)
Species Disease Transmission/ Vector
R. prowazekii Epidemic Thyphus/ Louse Louse feces
Bourne typhus
R. Prowazekii Brill Zinsser Disease/ No vector/ Recrudescence of
Recrudescent typhus (severe latent infection/ Relapse of
type) past-infection
R. prowazekii Flying squirrel typhus fever Presumably feces of flea or
louse of flying squirrel
R. Typhi Murine typhus/ Endemic Orienta; Rat Flea/ Cat Flea
typhus
 SCRUB TYPHUS GROUP/ ORRIENTIA
REPLICATES IN CYTOPLASM
SPECIES DISEASE MOT/ VECTOR
R. Tsutsugamutshi/ Orrientia Scrub typhus Chigger/ Mite bite (L. delenss)
tsutsugamutshi

COXIELLOSIS
SPECIES DISEASE MOT/ VECTOR
Coxiella burnetti Q (Query) Fever  Inhalation of aerosols from infected animals,
possibly ingestion of animal products
 Inhalation of birthing fluids
 Ingestion of unpasteurized Milk

 Intracellular inside (PHAGOLYSOSOMES) Lives ACIDIC ENVIRONMENTS: inactivates

 Spore formers metabolic enzymes:
 NOT ARTHOPOD TRANSMITTED Inc Liver enzymes, ESR, thrombocytopenia
 BARTONELLOSES
• Infects Red Blood Cell
• Highly Contagious
• Abrupt High Fever
• Cardiovascular system: MOST SUSCEPTIBILITY
Species Disease Transmission/ Vector
B. bacilliformis Carrions dse/ Orroya/ Verruga Sandfly bite
peruana
B. henselae Cat Scracth dse Kitten Scratch or Bite
Peliosis hepatitis
B. elizabethae Endocarditis, Bacteremia Bite of Rat fleas
B. quintana/ R. quintana Trench fever Feces of pediculus louse
 EHRLICHIOSES/ ANAPLASMA
• Infects WBCs

Species Disease Incubation Transmission/ Vector

E. chaffensis Human Monocytic 5-10 days Tick Bite (A. americanum)
Ehrilichiosis (HME)
-Morulae on monocytes
E. Phagocytophilia Human Granulocytic 5-11 days Tick Bite (I. scapularis/ I
ehrlichiosis/ Anaplasmosis pacificus)
-Morulae on Granulocytes
E. sennetsu Sennetsu Rickettsiosis Tick bite

 Many asymptomatic • Lab tests results: Leukopenia, Neutropenia, Inc Liver

 Pediatrics (RASHES) enzymes, thrombocytopenia
 Adult (rare) • Giemsa/ Wright: using Blood/ Buffy coat
• For observation of Morulae in WBC’s
 MILK BACTERIOLOGY
COLOR MILK CAUSATIVE AGENT
Blue Milk P. syncyanea
Blue/ Green Milk P. aeruginosa
Red Milk Serratia marsecens
Yellow Milk Flavobacterium synxathum
Souring Milk Streptococcus lactobacilli
Proteolytic acetoin on B. Subtilis/ hay bacillus
coagulate milk
Slimy/ Ropy Milk Alkaligenes viscosus
WATER BACTERIOLOGY
REFERENCES

• MICROBIOLOGY BOOK MAHON 5TH AND 6TH EDITION

• BACTERIOLOGY NOTES BY MA. CHRISTINA LIWANAG

• RYAN M. PEDREGOSA, RMT MICRO-PARA NOTES