Problem-Based Microbiology

2008
(4) Diphtheria
Corynebaterium diphtheriae
Recent emigrant w/
unknown immunizations
Yellowish, leathery thick
membrane in pharynx
Bull neck bilateral
cervical adenopathy

Gm+ clubs, non-motile,
non-hemolytic, catalase+,
aerobic
Tellurite medium
Diptheria toxin
Diphtheria A-B exotoxin
affects Elongation Factor
2 blocking protein
synthesis leading to cell
necrosis
Upper respiratory
droplets, direct contact

Tx: Diptheria antitoxin

(10) Bacterial pneumonia
Klebsiella pneumoniae
Alcoholic, homeless
Thick, blood-tinged
sputum (currant jelly)
RUL infiltrate with
cavitary lesion (abscess)

Gm- short plump bacilli
Lactase+, Urease+,
Indole-
Capsular polysacchride
(CPS), K antigen
Most common Gm-
pneumonia, nosocomial
CPS are antiphagocytic,
molecular mimicry with
C3b and prevents
alternative complement
pathway, inflammation
Aspiration pneunomia

Tx: Piperacillin
(15) Post-Primary Tuberculosis
Mycobacterium tuberculosis
Recent emigrant
Fever, cough, night sweats,
weight loss
Chronic cough w/ blood-
tinged sputum
RUL infiltrates

Acid-fast, long bacilli cord
Multinucleated giant cells
Cord Factor, phenolic
glycolipids (LAM)
Infects macrophages
(recognize LAM) inhibits
phagolysosome fusion, cord
factor damages PMNs, form
granulomas w/ large
multinucleated giant cells
Airborne transmission

Tx: Isoniazid+Rifampin+
Pyrazinamide+Ethambutol
empirically, later INH+RIF
only if susceptible
(17) Histoplasmosis
Histoplasma capsulatum
5 workers demolish
building near Ohio river
Pigeon droppings
Multiple nodular
infiltrates, cavitary lesion
in RML, popcorn
calcification

Mold in soil, yeast in
humans
Giemsa, Wright stains
Yeasts grow in inactivated
macrophages (histiocyte)
causing granuloma
formation, disseminate
via lymph, cytokines
Ohio/Mississippi river
valleys, soil with bat/bird
droppings

Tx: Itraconazole
(Amphotricin B if severe)
(18) Blastomycosis
Blastomyces dermatitidis
Tennessee landscaper
Painful R arm verrucous
skin lesion, pustular
Multiple nodular
cavitating lesions in LUL
Unresponsive to
cefuroxime/erythromycin

White fluffy mold, large
budding yeast in humans

Neutrophils recruited
forming suppurative/
granulomatous
inflammation, focal
microabscesses in
papillary dermis
SE US, wooded areas

Tx: Itraconazole
(Amphotericin B if severe)
(19) Coccidioidomycosis
Coccidioides immitis
Recently visited Arizona
Erythema nodosum on
back
Infiltrates in both lungs,
large cavity in RUL

Branching septate hyphae
mold in soil, non-budding
spherules in humans
forming endospores
Spherule in terminal
bronchiole causes chronic
granulomatous
inflammation, can
disseminate to skin
SW US, arid soil around
rodent burrows

Tx: Itraconazole
(Amphotericin B if severe)
(22) Pneumocystis Pneumonia
Pneumocystis jiroveci
Has AIDS with thrush
Bilateral air-space
consolidation with
interstitial/alveolar
markings ground glass

Fungus, 5-8 um cysts
containing intracystic
sporozoites
Giemsa, Silver, DFA stain

Adhere to Type I
pneumocytes, cysts
rupture and fill alveoli,
decrease surfactant
secretion forming
foamy exudate
Immunocompromised

Tx: TMP-SMX
(26) Secondary Syphilis
Treponema pallidum
Multiple sexual partners
Hx of painless ulcers on
vulva
Maculopapular rash on
palms and soles, pustular
lesions and condylomata
lata on face

Spirochetes, obligate
human pathogens
Lipoproteins
RPR, VDRL tests
Chancre, indurated
painless ulcer, indicated in
primary syphilis.
Spread by lymph and
blood leads to a
maculopapular rash in
secondary syphilis.
Neurosyphilis (teritiary)
Sexual, congenital spread

Tx: Penicillin G
(doxycycline if allergic)
(30) Chlamydia
Chlamydia trachomatis
Multiple sexual partners
Lower abd pain, vaginal
discharge, dysuria,
cervical motion
tenderness
Pelvic Inflammatory
Disease

Gm- cell layers w/ LPS
Serotypes D-K most
common
Most frequently reported
STD in US
Elementary bodies (EB)
enter columnar epithelial
cells of cervix becoming
reticulate bodies (RB)
which multiply and
release EBs, inflammation

Tx: Doxycycline (and
cefoxitin for anerobes)

(31) Trichomoniasis
Trichomonas vaginalis
Sexually promiscuous
Yellow, foamy vaginal
discharge with foul odor
Strawberry cervix

Motile, pear shaped
Human-only host
Fishy odor with KOH test
No stippled clue cells
Inflammatory response
(vaginitis) with PMNs
present, direct damage
causes microulcerations,
increased vaginal pH
Most men asymptomatic

Tx: Metronidazole
(32) Candidiasis (Yeast Infection)
Candida albicans
Thick whitish vaginal
discharge
Vulvar itching
Denys sexual activity
Recent ATB use

Yeast with pseudohyphae,
produce chlamydospores
Yeast cell cultivation in
human serum yields
distinctive germ tubes
With disruption of normal
flora, C. albicans
overgrows on muco-
cutaneous surfaces
forming cottage cheese-
like discharge
Broad-spectrum ATB

Tx: Topical antifungals
(clotrimazole) or oral
fluconazole
(33) HIV-1
Human immunodeficiency virus type 1
Unprotected MSM
Diffuse maculopapular
rash on abdomen

Retrovirus
gp120, gp41
ELISA + Western Blot
gp120 binds to CD4 which
allows it to bind to CXCR4
(T-cells) or CCR5 (T-cells/
M) co-receptors.
gp41 leads to fusion and
cell entry
Sex, IV Drug Use,
Congenital spread

Tx: Combination anti-
retroviral therapy
(HAART)
(35) Salmonella
Salmonella typhimurium
Family has cramps,
vomiting, diarrhea
(bloody)
Ate turkey and stuffing

Gm- motile rods,
facultative anaerobic,
lactase-, oxidase-
Stool cultures
2
nd
leading cause of
food-borne disease
Localized invasion
results in influx of
neutrophils, can cause
bacteremia w/ LPS
inducing sepsis
Poultry, eggs, dairy

Tx: NONE (self-limiting)
(38) E. Coli O157:H7
Enterohemorrhagic Escherichia coli (EHEC)
Severe abdominal
cramps, watery turning
into bloody diarrhea
Ate pink hamburgers

Gm- rod, Indole+,
Lactase+, Sorbitol non-
fermenting
Stool cultures
Most common cause of
bloody diarrhea
Attaches to brush border
of intestinal epithelium
Shiga-toxins cause
endothelial damage
leading to blood loss
Ground beef,
unpasteurized milk

Tx: NONE (self-limiting)
(39) Cholera
Vibrio cholerae
Traveled to Bangladesh
Profuse rice-water
diarrhea, vomiting,
sweating, cramps
Taking H
2
-blocker drug

Gm-, comma-shaped
Motile, oxidase+,
faculatative anaerobe
Acid-sensitive
Cholera toxin (CTX)
Pandemic due to O:1
biotype El Tor
CTX activates adenyl
cyclase cascade
increasing cAMP,
accumulate NaCl in lumen
leading to dehydration
Contaminated water/food
Gulf coast US: shellfish

Tx: Rehydration therapy
(oral rehydration soln)
(42) C. difficile-associated diarrhea (CDAD)
Clostridium difficile
Frequent diarrhea
Erythematous, friable
colonic mucosa
Hx of broad spectrum ATB
treatment

Gm+, spore-forming rod,
strict anaerobe
Toxin A, Toxin B
Stool sampled for toxin
(ELISA)
Toxin B more potent,
inactivate GTP-binding
proteins causing break-up
of actin filaments
damaging cellular lining
Exposure to broad-
spectrum ATB
(clindamycin, cephalo-
sporin, ampicillin)

Tx: Metronidazole
(46) Amebic Dysentery
Entamoeba histolytica
Traveled to India
Intermittent diarrhea
with blood and mucus
Multiple small
hemorrhagic areas with
ulcers in sigmoid colon

Trophozoite in host and
infective cyst in feces
Cyst transforms in small
intestine and migrate to
large intestine, invading
colon causing cell and
PMN lysis, can cause
flask-shaped ulcers
Fecal-oral transmission

Tx: Metronidazole and
Paromomycin
(47) Giardiasis
Giardia lamblia
Backpacking in Rockies
Watery diarrhea turning
greasy and foul smelling

Trophozoite pear-
shaped, face-like
appearance, cysts in
stool
Stool antigen test
Trophozoites attach to
brush border causing
villus atrophy resulting
in diarrhea
Beavers, dog feces
contaminated water

Tx: Metronidazole
(48) Cryptosporidiosis
Cryptosporidium parvum
Untreated AIDS
Chronic watery diarrhea

Acid-fast, intracellular,
extracytoplasmic
coccidian oocysts
Ziehl-Neelsen staining
Oocysts release
sporozoites infecting the
jejunum between
microvilli, impairing
adsorption resulting in
water loss
Water-borne transmission

Tx: IV rehydration, restore
HAART
(49) Ascariasis
Ascaris lumbricoides
Originally from Mexico
Poor appetite, abd pain
Eosinophilia
Intestinal obstruction
Nematode eggs in stool

Largest human
roundworm
Eggs have bumpy coat
Larvae hatch, invade
intestinal mucosa, travel
through portal and
systemic circulation to
lungs and alveolar walls
(Loeffler syndrome).
Larvae are reswallowed.
Tropical regions, soil,
produce, children 3-8 yo

Tx: Mebendazole
(50) Strongyloidiasis
Strongyloides stercoralis
Traveled to El Salvador
3w worsening diarrhea,
abd pain, fevers
Eosinophilia
Maculopapular rash on
groin and buttocks

Rhabditiform larvae with
prominent genital
primordium
Filariform larvae
penetrate skin and
migrate to lungs where
they are reswallowed into
the jejunum causing GI
symptoms and can
reinfect peri-anally.
Humid tropical regions,
direct contact with soil
(walking barefoot)

Tx: Ivermectin
(51) Hydatid Cyst Disease
Echinococcus granulosus
Emigrated from Argentina
raising sheepdogs
Fever, chills, jaundice,
upper abd pain
Liver has large multi-
loculated cyst with bile
duct dilation

Tapeworm, 3 proglottids
Hydatid cysts
Oncospheres invade and
develop into cysts in liver,
lung, brain, etc. Can lead
to biliary duct dilation
and jaundice, hydatid
cysts cause abd pain
Dog feces

Tx: Surgery, Albendazole
(52) Schistosomiasis
Schistosoma mansoni
Recent immigrant from
Kenya
Eosinophilia
Hepatosplenomegaly w/
portal HTN
Vomiting w/ blood

Blood trematode
Egg w/ lateral spine
Cercariae penetrate skin
and migrate to veins, eggs
migrate but some are
trapped and die in tissue
causing granulomatous
rxn in liver and spleen.
Infected snails in open
water

Tx: Praziquantel
(53) Hepatitis A
Hepatitis A Virus (HAV)
Fever, jaundice, dark
yellow urine, pale stools
Sight of food triggers
nausea
High ALT and AST

Picorna ssRNA+
icosahedral capsid
Hepatitis panel serology
Replicates in liver, CTL
response, viremia, and
eventually cleared
Worldwide: Poor
sanitation, US: Shellfish

Tx: NONE (self-limiting)
(58) Meningitis
Listeria monocytogenes
Headache, confusion, no
nuchal rigidity
Hx: Steroid use for RA
MRI show meningeal
enhancement

Gm+, intracellular small
rods, grow at 4C, -
hemolysis, tumbling
motility, ferment glucose.
Internalin, listeriolysin O,
phospholipases
Internalin induces host cells
to engulf. Phospholipases
allows it to escape
phagosomes, spread via
pseudopods. Killed by T cell-
mediated activation of M.
Meningitis in newborns
Processed meat, soft
cheeses

Tx: Ampicillin +
Aminoglycoside
(67) Osteomyelitis
Staphylococcus aureus
Spreading painful, warm,
tender, necrotic-appearing
boils on L leg with fever.
Bone scan shows intense
uptake in femur

Gm+ cocci, clusters,
catalase+, coagulase+, -
hemolytic
Protein A, hemolysins,
hyaluronidase, leukocidin
Most common cause of skin
infections
Fibronectin-binding protein
causes colonization in skin
breaks that invade the
mucosal barriers, makes
pyogenic exudate, spreads
locally or hematogenously
to the bone (osteomyelitis)
Human nasal carrier

Tx: Nafcillin (Vancomycin if
MRSA)
(68) Necrotizing Fascitis
Streptococcus pyogenes
Severe pain, swelling in L
thigh, purplish becoming
rapidly grayish

Gm+ cocci in chains, -
hemolysis, facultative
anaerobic, catalase-,
bacitracin-sensitive
Hyaluronic acid, M-
protein, LTA, hemolysin O
and S, enzymes
LTA-M protein binds to
epidermis and resist
phagocytosis, spread into
subcutaneous tissue,
dermis, and fascia via
hyaluronidase prompting
pyogenic inflammation.
Direct contact, types M1
or M3 common for skin

Tx: Surgery, Penicillin G
(clindamycin if allergic)
(69) Gas Gangrene
Clostridium perfringens
Severe pain at colon
carcinoma surgery site
Discolored skin,
hemorrhagic bullae,
serosanguineous (thin
brownish) discharge,
extensive gas in soft tissue

Gm+ box-shaped rods,
anaerobic, catalase-, double
-hemolysis, deep tissues
Nagler rxn (+ lecithinase)
Bowel surgery allows
anaerobes access to tissue
and flourish with facultative
anerobes. -toxin has
phospholipase C activity on
cell membranes, other
enzymes produce gas,
muscle turns black and
gangrenous
Normal human colon flora

Tx: Surgery, Penicillin,
Clindamycin
(71) Ringworm (tinea capitis)
Microsporum canis
Raised lesions with center
nodules and peripherial
scaling on head.
Received dog recently

Monomorphic fungi,
spindle-shaped macro-
conidia, white mold
Woods light (UV) on hair
Keratinases, proteinases
Only found in dead layer
of epidermis, keratinases
allow invasion of
keratinized tissue, snake-
like, annular, nodular,
vesicular lesions.
Found on cats and dogs

Tx: Griseofulvin
(concentrates in keratin),
OTC drugs
(72) Sporotrichosis
Sporothrix schenckii
Multiple mildly painful
erythematous lesions
starting from thumb to
elbow with lymphangitic
streaking.
Thumb has dry, shallow,
ulcerated lesion

Fungal dark-pigmented
mold in soil, cigar-shaped
yeasts in tissue, florally
arranged microconidia
Sabouraud dextrose agar
Rose handlers disease
Spores enter punctured skin
and form smooth/verru-
cose painless nodules,
spread via lymph forming
chains of nodules or
suppurating granulomas
(plasma cells, neutrophils)
Sphagnum moss, hay,
thorny plants

Tx: Itraconazole
(76) Native-Valve Endocarditis
Viridans streptococci
Night sweats, splinter
hemorrhage in fingernail,
conjunctival petechiae
Hx: Heart murmur
Hx: Wisdom tooth removal
w/ no ATB
Echo shows 8mm mobile
vegetation on bicuspid
aortic valve

Gm+ cocci in chains, -
hemolytic, optochin-
resistant
Results from transient
bacteremia with preexisting
valve abnormality. Minor
trauma from turbulence
leads to deposition of fibrin
and platelets, binding
bacteria forming micro-
colonies leading to Janeway
lesions, Osler nodes, Roth
spots, splinter hemorrhages
Normal oral/GI flora

Tx: Bactericidal ATB
(Penicillin G)
(77) Pneumonitis
Cytomegalovirus (CMV)
Moderate respiratory
distress, bilateral interstitial
infiltrates
Received allogeneic bone
marrow transplant, taking
Bactrim

-herpesvirus, dsDNA with
capsid and env, can progress
to latency
Giant cells (cytomegalic)
with intracellular inclusions
(with halo Owls eye)
Most common cause of
post-transplant infection
Multiplies in nucleus, enters
latent state in leukocytes/
lymphocytes, can cause
interstitial pneumonia on
reactivation (spreading to
pneumocytes)
Close contact with body
fluids (saliva)

Tx: Ganciclovir (Foscarnet if
resistant)
(78) Lyme Disease (LD)
Borrelia burgdorferi
Home in wooded CT
Multiple tick bites
Rash under armpit with
central clearing
Myalgia, arthralgia, fever

Spirochete, motile
OspA, OspB
ELISA + Western Blot
Ticks inoculate host,
spread outwards and
trigger inflammatory
cytokines, can cause
auto-immune Abs
Black-legged deer-ticks
US: NE, MN, WI, Pacific

Tx: Doxycycline
(79) Malaria
Plasmodium falciparum
Immigrated from W Africa
Intense periodic fevers,
drenched in sweat
Hepatosplenomegaly
Generalized seizure

Protozoa with 4 stages: ring
(around central vacuole),
trophozoite (Schuffner
dots), schizont (chromatin
dots), gametocyte
(crescent-shaped).
Thick/thin film blood smear
Sporozoites infect liver cells,
mature and invate RBCs
(Duffy Ag) and feed on Hg
leading to anemia,
thrombocytopenia,
hypoglycemia, lactic
acidosis. Can persist in liver
Mosquitos

Tx: Chloroquine
(Primaquine for liver
infections, mefloquine if
resistant, exchange
transfusion if severe)
(81) Leptospirosis
Leptospira interrogans
Recently returned from
boating trip in August
High fever, myalgia,
severe HA, photophobia
Swollen conjunctiva

Spirochetes, long, thin,
motile with hooked ends
ELISA, microagglutination
test (MAT)
Hooked ends and flagella
allows burrowing into
tissues leading to
bacteremia followed by
inflammatory and
immune response which
can lead to jaundice
Rat or livestock urine

Tx: Oral doxycycline (IV
penicillin if severe)
(82) Pasteurellosis
Pasteurella multocida
R hand and axilla was
swollen and tender
Hx: Bitten by cat

Gm- short rods,
oxidase+, encapsulated
Chocolate agar
Bipolar staining
Polymicrobic, capsule
and endotoxin trigger
inflammation with
purulent drainage
Cats (sometimes dogs)

Tx: Penicillin G
(84) Smallpox
Variola major
Papulovesicular lesions
on face and extremities
at same stage of
development, bumpy
lesions filled with
opaque fluid
Already had chickenpox

Herpes, linear dsDNA,
dumbbell-shaped core
Eradicated worldwide
After week-long
incubation, flu-like
symptoms, maculo-
papular rash on face,
palms, soles.
Bioterrorism agent

Tx: NONE (self-limiting)
(85) Plague
Yersinia pestis
Lives in Arizona
Painful L groin mass, firm
and tender
Small hemorrhages on skin
of R leg

Gm- safety-pin shaped,
nonmotile, oxidase-,
ferment glucose, reduce
nitrates
F1 glycoprotein, protease,
coagulase, exotoxin
Wright stain
F1 avoids phagocytosis and
multiplies in M, spread to
lymph nodes forming
buboes and can cause
bacteremia, widespread
petechial lesions from
vascular necrosis if systemic
Rodents, carnivores, cats,
dogs are animal reservoirs
Flea vectors

Tx: Streptomycin
(88) Hantavirus Pulmonary Syndrome (HPS)
Sin Nombre Virus
Fever, malaise, muscle
aches, hypotension, SOB
Camping in rural NM with
deer mice
Bilateral interstitial
infiltrates with hilar
indistinctness
Left-shift (22% bands)

Bunyavirus, spherical,
circular ssRNA-, triple-
segmented
Serology, RT-PCR
Attach to cells at b3 integrin
receptor, replicate in
cytoplasm, initiate TNF, IL-2
response. Activated CD8 T-
cells produce holes in
infected pneumocytes
leading to bilateral
infiltrates, left-shift,
thrombocytopenia,
pulmonary edema,
hemoconcentration
Rodent urine or droppings

Tx: Supportive care
(91) Severe Acute Respiratory Syndrome (SARS)
SARS Coronavirus
Mild SOB, hypoxia
Hx: Care of patient with
severe respiratory illness
Bilateral lower lobe
interstitial infiltrates

Coronavirus, ssRNA+,
enveloped with club-
shaped peplomers,
nonsegmented
Infection leads to diffuse
alveolar damage (DAD),
multinucleated giant cells
with no viral inclusions,
squamous metaplasia,
increased fibrosis
Respiratory droplets

Tx: Supportive Care