QUIZ 7

1. QUIZ 7

2. What is the leading cause of Meningitis in adults? What are some virulence factors? Think: “My PAP got CAP from this organism. Since it is the leading cause of community acquired pneumonia and Meningitis.”

3. Streptococcus Pneumoniae • Features:Gram + Lancet shaped diplococci in pairs, part of Viridians Lancefield grouping. Appear Gram – as they get older. • Transmission: Colonizes the upper respiratory tract after a viral infection. Most common cause of community acquired pneumonia • Symptoms: Fever, chills, coughing with rusty sputum, consolidation on X-ray causingPneumonia, bacteremia, otitis media, sinusitis. Leading cause of Meningitis in Children and Adults • Virulence: • P- Pneumolysincontributes to pathogenesis inhibiting secretory IgA • A- Surface ProtienA in the Capsule is antiphagocytic • P- Resistant to Penicillin from Penicillin Binding Proteins. NOT Beta Lactamase • C- Catalase Negative- Cannot breakdown H2O2 and eventually can produce suicidal concentrations of H2O2 • A- Older bacterium have Amidasethat damages their cell wall and make them appear to be Gram - • P- Induce Polymorphonuclear neutrophil leukocyte response in host • Focal collections of pus, abscess (zits), or diffuse inflammation (cellulitis). • Induces congestion in the lungs causing lobar pneumonia. • Diagnosis: • Typically alpha hemolytic (incomplete hemolysis) that is inhibited by Optichinpaper. • Treatment: • Prevnar/PCV-13 Vaccine- Polysaccharide-protein conjugate vaccine given to children as young as 2 months old. Conjugated to Diptheria Toxoid. (Does not protect against Otitis Media in Children) • Pneumovax/ Pneumococcal Polysshccharide vaccine- given to adults at high risk and adults older than 65.

4. What should you think of when a patient has relapsing fevers after a tick bite?

5. BorreliaRecurrentisor Hermsii • Features: Helical spirochete, Gram -, • Transmission: Tick Bites or Lice that get scratched into the bite opening. • Symptoms: Relapsing Fever with rigors and headaches for 5-7 days. Many recurring episodes. • Virulence: • Undergoes Antigenic variation during infection allowing for more febrile episodes. • Diagnosis: • Blood smear stained with Wright or Giemsa, blood inoculated into young rats or mice • Treatment: • Penicillin, tetracycline, erythromycin or chloramphenicol

6. What should you think of when you see this? Hint:TicksBorre their HEAD into your skin.

7. Borreliaburgdorferi“Lyme Disease” • Features: Spirochete • Transmission: Tick bites in mice, deer, and then humans • Symptoms: red skin lesion ( looks like a bulls eye) containing spirochetes in 3-14 days at the site of tick bite. malaise, fatigue, headache, fever, chills, generalized achiness and enlarged regional lymph nodes. • Virulence: HEAD • OspE may combine with a host Factor Hleading to cleavage of (complement) C3b thus impairing host resistance. • Outer surface protein A (OspA) is expressed by the organism when it is in the alimentary tract of ticks • Weeks to months later the patient Develops a migratory polyarthritis, carditis, or neurologic abnormalities from organisms in protected niches. • Diagnosis: • Serology • Immunoflurescent staining • Treatment: • β-lactam (amoxicillin) or tetracycline's (doxycycline) (best treated early)

8. What should you think of when a patient gives a urine sample and spirochetes are found? Hint: Do you know your vowels?

9. Leptospirainterrogans“Leptosparusis”(sp) • Features: Spirochete • Transmission: Reservoir in small mammals and pets that urinate into water and humans get infected after drinking it or getting the water on open wounds. • Symptoms: 2 types • Anicteric: Mylagia, headache, abdominal pain, fever that progresses to Meningitis and Rash with fever. • Icteric: Jaundice, hemorrhage, renal failure, myocarditis • Virulence: • Differentiated based on O-antigens • Produce Hemolysins- (lyse RBC’s) • Persists in renal tubules and is excreted in urine • IgM’s made after infection provide immunity and cause some of the problems • Detectable in blood during first stage • Detectable in CSF and Urine during second stage • Diagnosis: • Find agglutinating antibodies • Cultures of blood are slow and microscopy is unreliable. • Early Treatment:Penicillin, streptomycin, ceftriaxone, doxycycline, particularly effective if given Early; amoxicillin

10. What should you think of when a patient has painful inguinal lymphadenopathy, flee bites, and Wayson stain with safety-pin appearance and is form Arizona? Hint: “FLEES SPIL’N FRYS that burned this girls leg.”

11. Yersinia Pestis“Bubonic Plague” Flees are the vector Safety Pin Inguinal Lymphadenopathy Negative gram stain F1antiphagocytic protein Rodent resivior YopsType III secretion SyndromePneumonic • Features: Facultative anaerobic, non-motile, Gram Negative bacterium. Safety Pin Appearance. • Transmission: RODENTS, Squirrels and Prairie dogs are a reservoir in Arizona. Transmitted by FLEE BITES. • Symptoms: Fever, painful unilateral Inguinal Lymphadenopathy, nausea, back pain. Septic patients get hypotension. Can have a cough with bloody sputum if pneumonic. • Virulence: • Encapsulated and has rough LPS • AntiphagocyticF1 Protien • Type III secretion of Yopswhich inhibits phagocytosis and innate immune response • Causes coagulation of blood • Septic individuals will have vascular collapse and gangrene. • Infected individuals can pass disease with respiratory droplets called Pneumonic Syndrome. But more likely comes from disseminated Bubo infection. VERY CONTAGIOUS. • Diagnosis: • Aspirate and culture of Bubo, sputum or blood • Culture on MacConkey agar which stains for lactose fermentation. Fermenters will have a low pH. Non-fermenters will make the pH higher. • Treatment: Streptomycin or Tetracycline

12. What should you think of when a child gets bites from playing in the woods and shows up with these spots (rash)? Hint: This girl likes to listen to the Rocky Mountain RADIO STN.

13. Rickettsia rickettsii “Rocky Mountain Spotted Fever” • Features:Gram-Negative,obligate Intracellular bacteria that cannot be easily cultivated in the clinical lab • Transmission: Tick Bites! Typically children playing in the woods. • Symptoms: Fever, headache, and chills. nausea vomiting, myalgia, Spotted Rash after 2 days appears on wrists, ankles, soles and forearms and then moves to the rest of the body. • Virulence: • Found in April and September • Diagnosis: PCR, IHC of skin biopsy. • Treatment: Doxycycline Rocky Mountain Rickettsia Rickettsii April to September Doxycycline Intracellular Orphans/ kids in Appalachia Spotted Rash Tick Bite Negative Gram Stain

14. What should you think of when a homeless person with body lice tells you they have a history of Brill-Zinsser disease? Hint:“ Typhus is Homeless and has REALBIGPROblems.”

15. Rickettsia prowazekii“Typhus” • Features: Gram-negative, obligate intracellular bacteria that cannot be easily cultivated in the clinical lab. • Transmission: Body Lice. Found in homeless and refugee camps. • Symptoms: Chills, Cough, Delirium, High fever (104 degrees Fahrenheit), Joint pain (arthralgia), Photosensitivity, Low blood pressure, Rash that begins on the chest and spreads to the rest of the body (except the palms of the hands and soles of the feet), Severe headache, Severe muscle pain. • Virulence: • Causes Brill-Zinsser disease when it reactivates • Infection spreads via lymphatic's • Attaches to vascular endothelium • Spreads via actin-mediated propulsion causing vascular injury • Diagnosis: Serology for antigens • Treatment: Tetracycline/ Doxycycline or Chloramphenicol Typhus is Homeless and has Reactivates as Brill Zinser Endothelialattachment Actinmediated propulsion Lymphatic's spread disease BodyLice Intracellular Gramnegative Problems “Rickettsia Prowazekii”

16. What should you think of when a homeless person has been eating unpasteurized goat cheese from Mexico and has back pain? Hint: “Unpasteurized BLAC BUNNI milk.”

17. Brucella “Brucellosis” • Features: small, non-motile, gram- rods. Facultative intracellular pathogens. • Transmission: Ingestion of unpasteurized GOAT cheeses, milk, or from direct contact. No insect vector. • Symptoms: Fever, sweats, malaise, myalgia, anorexia, headache, back pain, weight loss, anorexia, mild lymphadenopathy • Virulence: • Can Be Undulant or Chronic if they form granulomas in bone, joints, liver, spleen, or kidney • organisms spread to regional lymph nodes from sites of infection • Survives within APC’s =macrophages and dendritic cells • Give rise to granulomas in liver and bone marrow • Urease positive • Diagnosis: • Acute: Isolation and Identification in blood and tissue • Tube Aggulutination titer greater than 1:160 • Treatment: Doxycycline and Streptomycin for 6 weeks Unpasteurized Milk Brucellosis Lymphatic Spread Apc’s are infected Chronic granulomas Back Pain Urease positive Negative gram stain No Insect Vector Intracellular-Tx: Doxycycline

18. What should you think of when a person has an open wound that their dog or cat licked and caused them fever and regional lymphadenopathy? Hint: “The cat bit GraNPAP!.”

19. Pasteurellamultocida • Features: Non-motile, gram-negative coccobacilli • Transmission: Dog and Cat bites • Symptoms: Inflammation, swelling, tenderness at bite site, regional lymphadenopathy, and fever. • Virulence: • Fails to grow on MacConkey agar • Diagnosis: Culture of the aspirate at bite site • Treatment: Penicillin G, Penicillin VK, ampicillin, amoxicillin. Are considered polymicrobialbecause they often include Staph Aureus or Streptococcus. For this reason prophylaxic antibiotics are given. The Cat bit = Cat and dog bites GraN- Gram Negative PasturellaMultocida Aspirate for culture Prophylactic antibiotics because it is polymicrobial, containinfStaph Aureusand Streptococcus

20. What should you think of when a patient comes in with these lesions?

21. Bacillus anthracis “Anthrax” • Features: Gram +, spore forming rod found in chains • Transmission: Scratches from wool or from inhalationof some soils. Humans are accidental hosts. • Symptoms: Fever, malaise and inflamed lesions on his hands and arms. Creates Black Scabs on lesion site. • Virulence: • Protein capsule is antiphagocytic • Production of AB toxins • Lethal Factor: A subunit- a Zinc metalloprotease that interferes with intracellular signaling cascades • Edema Factor: A subunit- a calmodulin-dependent adenylatecyclase • Protective Antigen: B subunit- combines with both A subunits to transport them into the host cell. • Diagnosis: Swabs of the lesions and gram stain. • Treatment: • Penicillin- cutaneous • Ciprofloxacin- systemic • Vaccine is available, AVA, containing Protective Antigen

22. What should you think of when a patient comes in with these bumps on their penis but has no pain?

23. Molluscumcontagiosum • Features: Pox virus, enveloped, dsDNA • Transmission: Direct contact in children or from sexual contact. • Symptoms: lesions which begins as a small papule and gradually grows into a discrete, waxy, smooth, dome-shaped, pearly or flesh-colored nodule. Found on the trunk mainly and pubic areas in adults. Painless. • Virulence: • Last 6-9 months • Has transcriptase, TF’s, polymerase, capping enzyme, and methylating enzyme. • Enters cell via endocytosis • Enveloped and non-enveloped particles are infectious • Diagnosis: EM and clinical appearance • Treatment: Burn them off

24. What disease has a rash all over the body (soles of feet and palms included) where all of the lesions are in the same stage?

25. Variola “Small Pox” • Features: Pox virus, enveloped, dsDNA • Transmission: Inhalation of viral particles • Symptoms: Muscle aches and fever at first. 2 weeks later rash appears that spreads all over including palms and feet. All of the lesions are in the same stage of development. • Virulence: • Eradicated in 1977 • Low infectious dose • Has transcriptase, TF’s, polymerase, capping enzyme, and methylating enzyme. • Enters cell via endocytosis • Enveloped and non-enveloped particles are infectious • Diagnosis: EM and clinical appearance • Treatment: • Vaccination if before 5 days infection works as a treatment. Vaccination lasts 10 years but has complications. • Causes severe eczema, fatal disease, or encephalitis.

26. What should you think of in a patient who just got back from Africa on safari and had vomit that is black? Ps. They never got their vaccines before traveling.

27. A. Aegypti“Yellow Fever” • Features: Flavivirus, +RNA • Transmission: Mosquito bites in traveler to Africa and South America • Symptoms: Can be either a mild febrile illness or severe with: high fever, chills, headache, muscle aches, vomiting, and backache. Can then lead to Hemorrhages with BLACK VOMIT. • Virulence: • Attach to Fc receptor of macrophages and monocytes for uptake • Inflammatory response to infection causes encephalitis • Alpha and BetaInterferon's cause flu symptoms • Unique: Virus buds into intracellular vesicles and exocytosed • Diagnosis: ? • Treatment: Vaccine available.

28. What should you think of in a patient who has fever, rash, headache, and severe muscle and bone pain?

29. Dengue Virus “Break Bone Fever” • Features: Flavivirus, +RNA • Transmission: Mosquito Bites • Symptoms: Fever, Rash, Headache= Dengue Triad. Also eye pain, joint pain, mild bruising, and easy bleeding, severemuscle and bone pain • Virulence: • Hemorrhagic fever happens with second infection that produces a cross-reaction between neutralizing antibodies • Four Serotypes cause disease: DEN 1,2,3,4. Very Common. • Attach to Fc receptor of macrophages and monocytes for uptake • Inflammatory response to infection causes encephalitis • Alpha and BetaInterferon's cause flu symptoms • Unique: Virus buds into intracellular vesicles and exocytosed • Diagnosis: • Treatment: Hydration and Acetominophen

30. What should you think of in a patient who is a house keeper in the mountains with acute fever and respiratory illness and claims to have recently been sweeping up mouse shit?

31. Hantavirus- “Sin Nombre” • Features: Bunyavirus, -ssRNA, • Transmission: Carried by deer mice feces that are areosolized by aggitation. • Symptoms: fever, myalgia, malaise; often- nausea, vomiting, and abdominal pain, dizziness that rapidly progresses to pulmonary edema, hypoxemia, and respiratory failure. • Virulence: • Replicates in the cytoplasm • Strain in Asia effects the kidneys • Diagnosis: • IgM and IgG to Hanta Virus • RNA RT-PCR • Treatment: Supportive Care

32. What should you think of in a patient who is a house keeper in Africa with acute fever, respiratory illness, retrosternal pain and claims to have recently been sweeping up mouse shit?

33. Lassa Fever • Features: Arena Virus, Sand-like particles on the surface, -ssRNA, buds from cell-surface. • Transmission: Contact with Rodent urine or inhaling aerosolized particles. Found in Africa. • Symptoms:fever, malaise; general weakness that progresses retrosternal pain, vomiting, conjunctivitis, facial swelling, proteinuria, mucosal bleeding, and neurological problems such as hearing loss, tremors, and encephalitis Progresses to ARDS. • Virulence: • Long-term complication is Deafness and hair loss and gait disturbances. • Diagnosis: • Serum Test for Lassa Fever • IHC staining • RT-PCR • Easily confused with Typhoid Fever, Dengue, or Malaria. • Treatment: Ribvirin “I LASSA my hearing”

34. What should you think of in a patient with hemorrhagic fever after spending time in a cave breathing bat shit?

35. Ebola • Features: Filovirus • Transmission: Bat Shit • Symptoms: Fever, headache, vomiting, diarrhea that progresses to GI bleeding, Shock, and Intravascular coagulation caused by thrombocytopenia. • Virulence: Hemorrhagic Fever • Diagnosis: RT-PCR, ELISA for virus • Treatment: • MOST LETHAL VIRUS • Supportive Care

36. What should you think of in a California patient with Unilateral periorbital swelling, tender lymphadenopathy and this in their blood?

37. Trypanosomacruzi “American Trypanosomiasis” • Features: Protozoa “Chaga’s Disease” • Transmission: Transmitted in Kissing Bug/Triatomine bites • Symptoms:Unilateral periorbital swelling, tender lymphadenopathy, hepatosplenomegaly, encephalitis,later(20% of patients) cardiomyopathy, megaesophagus, megacolon • Virulence: • MetacyclicTrypomastigotesin kissing bug fecesenter bite site. Infection • Amastagotes are found inside infected muscle of host. Diagnostic. • Diagnosis: • Microscopic exam: • of fresh blood, or buffy coat, for motile parasites • of thin and thick blood smears stained with Giemsa • Treatment: • Nifurtimox- bioreduction of the nitro-group to a nitro-anion radical which undergoes redox-cycling with molecular oxygen. Not active against Amastagotes. • Allopurinol- Xanthine Oxidase inhibitor • Albendazole/Mebendazole- Succinate dehydrogenase Inhibitors “Santa Cruzi CA is a great place to take a nap.”

38. What should you think of in an African safari patient with a chancre, fever, tender lymphadenopathy and this in their blood?

39. Trypanosomabrucei and gambiense “African Trypanosomiasis” • Features:Protozoa • Transmission: Bite of Tsetse Fly taking a blood meal. • Symptoms: Chancre, myalgia, arthralgia, lymphadenopathy, recurrent fever; later mental changes, sensory disorders, heart failure; • Virulence: • Found in West Africa and is LESS Virulent • MetacyclicTrypomastigotestransmitted through bite siteof Tsetse Fly • Diagnosis: • Microscopic exam of chancre fluid, lymph node aspirates, blood, bone marrow, CS fluid. Fluid concentration may be necessary. • Treatment: • Pentamidineisethionate- Treats hemolymphatic stage • Melarsoprol- used for late disease with CNS involvement

40. What should you think of in an African safari patient with a chancre, fever, tender lymphadenopathy that rapidly progresses to heart failure? And this is still in their blood.

41. Trypanosomabrucei and rhodesiense “African Trypanosomiasis” • Features: Protozoa • Transmission: Bite of Tsetse Fly • Symptoms:Chancre, myalgia, arthralgia, lymphadenopathy, recurrent fever; later mental changes, sensory disorders, heart failure. • Virulence: • Found in East Africa and MORE Virulent and Rapid • MetacyclicTrypomastigotestransmitted through bite siteof Tsetse Fly • seroconversion with rhodesiense occurs after the onset of clinical symptoms • Diagnosis: • Microscopic exam of chancre fluid, lymph node aspirates, blood, bone marrow, CS fluid. Fluid concentration may be necessary. • Isolation of the parasite by inoculation of rats or mice • Treatment: • Suramin- Treats hemolymphatic stage • Melarsoprol- used for late disease with CNS involvement

42. What kind of Malaria do I have? Hint: the organism looks like a flaccid…

43. Plasmodium falciparum “Malaria” • Features: • Transmission: Mosquitos taking a blood meal • Symptoms: Fever, Dark Urine, headache, rigors, vomiting, myalgia, diaphoresis, hemolytic anemia; later fever may become synchronous (48-72h) with splenomegaly • Virulence: • Human to human through mosquito vectors • Schizontsnot seen in peripheral blood unless infection is very heavy • These stages are sequestered in the liver and spleen • NO hypnozoitesin the liver, so no relapses. • Cerebral disease in severe malaria can be rapidly fatal • Untreated malaria can progress to severe forms that may be rapidly (<24h) fatal • Diagnosis: • Best is microscopic exam of blood • RT-PCR if trained microscopist not available • Treatment: Many resistant strains • 1stChloroquine- Can be given to pregnant women • 2ndMefloquine or Doxycyclineor Arthmether

44. What kind of Malaria do I have? Hint: “Hey guys, I have a great name for out rock band...Rock Band! Kinda catchy huh?” Notice the banding pattern. -So…Rock band is to Rock Band as this form of Malaria is to _____.

45. Plasmodium malariae “Malaria” • Features: • Transmission: Mosquitos taking a blood meal • Symptoms: Fever, Dark Urine, headache, rigors, vomiting, myalgia, diaphoresis, hemolytic anemia; later fever may become synchronous (48-72h) with splenomegaly • Virulence: • Human to human through mosquito vectors • schizonts are present in peripheral blood • NO hypnozoites in the liver • no relapse, but recrudescence can occur after 40yrs • Untreated malaria can progress to severe forms that may be rapidly (<24h) fatal • Diagnosis: • Best is microscopic exam of blood • RT-PCR if trained microscopist not available • Treatment: Many resistant strains • 1stChloroquine- Can be given to pregnant women • 2ndMefloquine or Doxycycline or Arthmether

46. What kind of Malaria do I have? Hint: Looks like a birds egg… What shape is a birds egg? What is marked by the hatching of a bird from the egg?

47. Plasmodium vivax and Plasmodium ovale “Malaria” “Birds eggs are OVAL and VIVA means life in Spanish.” Hope that makes you proud Horacio • Features: • Transmission: Mosquitos taking a blood meal • Symptoms: Fever, Dark Urine, headache, rigors, vomiting, myalgia, diaphoresis, hemolytic anemia; later fever may become synchronous (48-72h) with splenomegaly • Virulence: • Invade immature RBCs so cell membranes are easily distorted • Hypnozoitesdo occur in the liver • Relapses common for many years after acute infection • Untreated malaria can progress to severe forms that may be rapidly (<24h) fatal • Diagnosis: • Best is microscopic exam of blood • RT-PCR if trained microscopist not available • Treatment: Many resistant strains • 1stChloroquine- Can be given to pregnant women • 2ndMefloquine or Doxycycline or Arthmether • Primaquine prevents P. vivax and P. ovale

48. What kind of Malaria do I have? Hint: This one looks like it has little stars in it, letting you know that it is a trick most babies would fall for. But not you

49. Babesiamicroti “Babesiosis” • Features: Found in the USA and World • Transmission: Tick Bite • Symptoms: Fever, rigors, myalgia, hepatomegaly, hemolysis. • Virulence: • Mimic’s Malaria • Relapse is common • Can be transmitted via blood transfusion • Rings vary in size • No hemozoinpresent • Merozoites at basal or apical ends to create star-like arrangements. • Diagnosis: • Blood Smear detection • Antibody tests to rule out Malaria • Treatment: • Clindamycin plus quinine • Atovaquoneplus azithromycin

50. What should you think of when a patient has fever, hives, and eosinophilia after swimming in nasty water on vacation over seas ? Hint: “Swimming in overseas toilet water might get you covered in @#%&. Which caries an organism that likes to lays it eggs in your venules once your infected. See pic below.”