PW Micro Farre Z

Contents
1. General Microbiology·································································································2
2. Immunology············································································································· 19
3. Hospital Infection Control························································································ 39
4. CVS Infections········································································································· 43
5. GIT Infections·········································································································· 87
6. Hepatobiliary Infections························································································· 110
7. Skin & Soft Tissue Infections················································································· 116
8. Respiratory Infections···························································································· 153
9. CNS Infections······································································································· 184
10. Urogenital Infections···························································································· 213
11. Miscellaneous Topics·························································································· 226
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General Microbiology
1. Write the difference between exotoxins and endotoxins produced by bacteria.
(3 Marks)
Answer:
Feature Endotoxins Exotoxins

Nature Lipopolysaccharides Proteins
Source Part of the cell wall Secreted by bacteria

of gram-negative
bacteria
Released by Cell lysis, not by Heat labile, destroyed at 60° C
secretion
Heat stability Highly stable Mostly enzyme-like action
Mode of action IL-I and TNF-alpha Specific action on particular

increases tissues
Effect Nonspecific (fever, Specific affinity for tissues
shock, etc.)
Fatal dose Only large doses are Highly antigenic
fatal
Antigenicity Poorly antigenic Neutralized by specific
antibodies
Neutralization by Ineffective Toxoid forms are used as vaccine
antibodies
Used for vaccine No effective vaccine is Used widely
available
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd
Edition, Page No. 71
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MedEd FARRE: Microbiology
2. What is the difference between Gram-positive and Gram-negative bacterial cell

wall? (3 Marks)
Answer:
Characters Gram-positive cell wall Gram-negative cell wall

Peptidoglycan layer Thicker Thinner
At the 3rd position of the L-Lysine present Mesodiaminopimelic acid

tetrapeptide side chain present
Pentaglycine bridge Present Absent
Lipid content Very less ~ 2% Around 15%
Lipopolysaccharide Absent Present as endotoxin
Teichoic acid Present Absent
Aromatic amino acids Absent Present
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3. (A) What is the Koch postulate? (5 Marks)
Are there any exceptions to these now? If so enumerate a few with examples.
(B) Explain bacterial growth curve?
Answer:
(A) Koch’s postulate is a set of rules that are to be fulfilled by a microorganism to be
accepted as the causative agent of that disease. There are 4 Koch postulates for
the same-:
The microorganism should be constantly associated with the lesions of the disease.
It should be possible
To isolate the organism in pure culture from the lesions of the disease
The same disease must result when the isolated microorganism is inoculated into
a suitable laboratory animal
It should be possible to re-isolate the organism in pure culture from the lesions
produced in the experimental animals.
An additional 5th was added later which is antibody to the causative organism
should be demonstrable in the patient’s serum.
Exceptions to Koch postulate
Over the years we discovered many diseases caused by a number of bacteria and
many not associated with one or more of the postulate but they still are the causative
agents of that disease.
For ex-
Mycobacterium leprae and Treponema pallidum cannot be grown in culture. These
can only be maintained in the animal model which serve as a reservoir of pathogen.
Neisseria gonorrhoea- It does not cause disease in animal models but can be grown
in a culture medium in the lab.
(B) Bacterial growth curve
When we inoculate a bacteria in a liquid culture media under favorable conditions it’s
growth follows a definitive course.
It has 4 phases:
Lag phase: This is the period between inoculation and the onset of bacterial growth.

After inoculating the medium, bacteria do not start growing immediately,
but they take time to accumulate enzymes and metabolites. Bacteria reach
maximum size at the end of the lag phase.
Logarithmic phase: During this phase, bacteria divide exponentially, resulting

in a linear growth curve. At this stage, bacteria are smaller and biochemically
active. It’s the perfect stage to carry out biochemical reactions. Homogeneously
Stained.
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Stationary phase: After the exponential phase, bacterial growth almost completely

ceases due to depletion of nutrients, accumulation of toxic products and autolytic
enzymes. The number of progeny cells formed is sufficient to replace the number
of cells that die, and there is approximately equilibrium between dying and
newly formed cells, so the number of viable cells remains constant. stay. At this
stage, bacteria become Gram variables. At this stage sporulation occurs. Bacteria
produce exotoxins, antibiotics and bacteriocins.
Decline phase: Bacteria gradually stop dividing completely. Continued cell death

due to nutrient depletion and accumulation of toxic substances reduces viable
counts rather than total counts.
Factors affecting bacterial growth are-
Oxygen
Carbon dioxide
Temperature
pH
Light
Osmotic effect
Moisture and desiccation
Mechanical and sonic stresses.
Edition, Page No. 4
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4. What are the various ways by which bacteria acquire resistance to antibiotics?
(5 Marks)
Answer:
Antibiotics are the agents that kill or inhibit the growth of bacteria.
Antibiotic resistance means the property of a bacteria to resist the effect of

antibiotics on its growth and ensure bacteria survival even in the presence of
antibiotics.
Mechanisms of antibiotic resistance are:
Antibiotic Resistance
Mechanism Bacteria
Targeted
Reduced Cell-wall Pseudomonas, Enterobacter, Imipenem,

Permeability Klebsiella Aminoglycosides,
Quinolones
Efflux Pumps Escherichia coli, Tetracyclines,

Enterobacteriaceae Chloramphenicol
Staphylococci Macrolides, Streptogramins
Staphylococcus aureus, Fluoroquinolones

Pneumococci
Enzymatic β-lactamase-producing β-lactam antibiotics

Inactivation bacteria
Aminoglycoside-modifying Aminoglycosides
enzymes-producing bacteria
Chloramphenicol Chloramphenicol
acetyltransferase-producing
Enterobacteriaceae
Modification of Target MRSA (methicillin-resistant Penicillin-binding protein
Site Staphylococcus aureus) (PBP-2a)
M. tuberculosis Ribosomal proteins, 16S

rRNA (Streptomycin).
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Antimicrobial susceptibility testing-

It is done to detect the sensitivity of the pathogens to the available antibiotics and
also determine the development of resistance.
Method Description Applicability
Disk Diffusion Method Suitable for rapidly Not suitable for slow-
growing pathogenic growing bacteria.
(Kirby Bauer)
bacteria.
Antibiotic diffuses through
the solid medium,
and susceptibility is
determined by the zone of
inhibition.
Interpretation based
on standard zone size
interpretation tables/
guidelines.
Dilution Testing Serial dilution of MIC is the lowest

antimicrobial agent, MIC concentration that
(Minimum Inhibitory inhibits microbial
Concentration) calculated. growth.
Can use agar or broth as
the diluent
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Epsilometer (E-test) Quantitative method using Determines MIC using

a predefined gradient of both dilution and
immobilized antibiotic on diffusion.
an absorbent strip.
Oval zone of inhibition
develops around the strip;
MIC is taken where the
ellipse intersects the strip.
Automated AST (e.g., Various automated systems Streamlined and efficient
VITEK 2, Phoenix) are available for AST. testing.
Provides identification and
susceptibility results.
Molecular Methods Detection of resistance Identifies specific genetic
genes by Polymerase mechanisms of resistance.
Chain Reaction (PCR)
Mutational drug resistance Transferable drug resistance
Resistance to one drug at a time Multiple drug resistance at the same

time
Low-degree resistance High-degree resistance
Resistance can be overcome by a Cannot be overcome by drug

combination of drugs combinations
Virulence of resistance mutants may Virulence not decreased
be lowered
Resistance is not transferable to other Resistance is transferable to other
organisms organisms
Spread to off-springs by vertical Horizontal spread
spread only
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5. Write the laboratory diagnosis of fungal infection in brief. (5 Marks)
Answer:
Clinical Assessment
Begin with patient history, symptoms, and risk factors for fungal infections (e.g.,
immunosuppression, recent antibiotic use, travel history).
Specimen Collection
Collect specimens based on the site of infection, such as skin scrapes, sputum, blood
for systemic mycosis, and CSF for cryptococcal meningitis.
Microscopy
Use 10% KOH to dissolve keratinous substances in tissue samples for fungal hyphae
visualization.
Perform Gram stain to identify yeasts (e.g., Cryptococcus) and yeast-like fungi
(e.g., Candida).
Utilize India ink and nigrosin stains for the demonstration of the Cryptococcus
neoformans capsule.
Use Calcofluor White Stain, which fluoresces under UV light, for fungal cell wall
detection.
Employ histopathological staining for fungal element detection in biopsy tissue
(PAS stain recommended).
Consider Gomori Methenamine Silver (GMS) stain as an alternative to PAS.
Use Lactophenol Cotton Blue (LPCB) for studying fungus grown in culture.
Culture
Use Sabouraud’s dextrose agar (SDA) as a common diagnostic medium.
Consider other media like Corn meal agar, rice starch agar, Brain heart infusion
(BHI) agar, blood agar, Niger seed agar, bird seed agar, and CHROMagar Candida
for specific purposes.
Identifyfungal colonies based on macroscopic appearance (growth rate,
pigmentation, texture, and colony surface characteristics).
Examine fungal mounts microscopically, focusing on hyphal type and sporulation
type.
Perform Cellophane tape mounts to capture colony impressions.
Immunological Methods
Detect antibodies using ELISA, immunodiffusion test, agglutination test, and
complement fixation test (CFT).
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Detect fungal antigens (e.g., beta-D-glucan) in clinical samples.
Utilize immunohistochemistry to detect antigens on cells in tissue sections.
Automated Identification Systems
Use MALDI-TOF and VITEK systems for accurate yeast and mold identification.

Molecular Techniques
Employ PCR and its modifications (e.g., multiplex PCR, nested PCR) for precise

fungal identification from cultures and samples.
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6. Write a brief account of the mechanism of gene transfer in bacteria.
(10 Marks)
Answer :
Introduction
Bacteria undergo genetic modification and acquire new genes through a mechanism
called mutation. Newly acquired genes are either vertically transmitted to progeny
as the cell divides or horizontally transmitted to other bacteria within the region.
Horizontal gene transfer

Horizontal gene transfer occurs in bacteria by a variety of methods including
Transformation (naked DNA uptake)
Transduction (by bacteriophage),
Lysogenic conversion
Conjugation (plasmid transfer)
1. Transformation
Transformation is when bacterial cells pick up random, loose DNA fragments from
their surroundings and incorporate these fragments into their chromosomes.
Mechanism of Transformation
When bacteria burst open (lyse), a lot of double-stranded DNA (dsDNA) is released
into their surroundings.
The ability to take up this DNA depends on how efficient the bacteria in the
environment are.
Some bacteria are "competent," meaning they're in the growth phase and have
specific factors (competence factors) that enhance transformation.
Bacteria with competence factors (e.g., S. pneumoniae) can absorb DNA from any
source, regardless of where it came from.
Long dsDNA fragments are contacted with competent bacteria,
bound to DMA-binding proteins on their surface, and nicked
by a nuclease.
One strand is degraded by the exonucleases of the recipient cell
The other strand is internalized by binding to competency-specific

proteins. This step requires energy.
The single strand enters the cell and integrates into the host
chromosome in place of the homologous region of the host DMA.
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2. Transduction
Bacteria can share parts of their genetic material using tiny viruses called
bacteriophages, which live inside bacteria.
Mechanisms of Transduction
When a bacteriophage moves from one bacterium to another, it can accidentally
carry some of the host bacterium's DNA with it. This transferred DNA gives the
receiving bacterium new traits from the donor DNA.
Bacteriophages can carry out two life cycles within their host bacteria.
Life cycle Description
Lytic or Virulence Cycle Bacteriophages multiply inside the host

bacterium.
↓
It creates many new phages.
↓
Eventually, it breaks open the host cell,
causing it to burst and die.
Lysogenic or Temperate Cycle The host bacterium remains unharmed.
Phage’s DNA integrates into bacterial DNA.

Lives peacefully within the host.
Can switch to the lytic cycle later.
Types of Gene Transfer

Generalized Transduction: This transfers any part of the bacterium's genetic code
to another bacterium. It often happens during the lytic cycle of certain phages.
Restricted Transduction: Unlike generalized transduction, this can only transfer
specific gene segments from the bacterial chromosome that are close to the phage
DNA.
The Role of Transduction
Besides chromosomal DNA, transduction is also a method of introducing episomes

and plasmids.
Drug Resistance: Transduction may be the transfer mechanism of bacterial genes
encoding drug resistance. For example, plasmid-encoded staphylococcal penicillin
resistance.
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Treatment: Transduction has also been proposed as a genetic engineering approach

to treat some inborn errors of metabolism.
3. Lysogenic conversion
During the lysogenic (or temperate) life cycle, phage DNA integrates into the
bacterial chromosome.
It becomes a prophage and replicates in sync with the bacterial DNA.
Prophages act as additional chromosomal elements that carry new genetic traits
and are passed on to daughter cells. This process is known as lysogenic conversion.
Virulence Enhancement:
Lysogenic phage DNA can contribute to bacterial virulence by encoding the

production of bacterial toxins.
For example, in Corynebacterium diphtheriae, the diphtheria toxin is encoded

by lysogenic phage DNA integrated into the bacterial chromosome.
Removing the phage from the toxigenic strain makes the bacterium non-virulent.

Phage-encoded toxins
Bacterial toxins encoded by lysogenic phages include:
Diphtheria toxin

Cholera toxin

Streptococcus pyrogenic exotoxin (SPE-A and C)

4. Conjugation
Conjugation is the process of transferring genetic material from one bacterium

(donor or male) to another bacterium (recipient or female).
This transfer happens when the two bacteria come into contact and create a
conjugative tube.
F+ X F- Mating
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F+ cells (also known as donor or male bacteria) contain a plasmid called the
F factor or fertility factor.
Bacteria lacking F factors are called recipient bacteria or female bacteria or F cells.
The F factor is a conjugative plasmid.
It harbors genes that code for the formation of sex pili (which aids in mating)
and self-plasmid transfer.
The F pili bring the donor cell and the nearby recipient cell closer together,
forming a connecting tube that connects the donor and recipient cells
During conjugation, plasmid DMA replicates through a rolling circle mechanism

and copies migrate within the conjugation tube to recipient bacteria.
Then, in the recipient, the incoming strand is copied to produce a full-length

F factor with ds-DNA. As a result, recipient (F-) cells become (F+) cells
and are able to combine with other (F-) cells.
Therefore, it is said that this masculinity trait (F+) can be infected with bacteria.
During F+ X F-binding, the chromosomal gene of the donor bacterium is

rarely transferred together with his F factor. Here, however, the donor’s
chromosomal genes may recombine with the recipient’s chromosome.
But, the frequency will be lower.
HFR Conjugation
Hfr cells have an F factor plasmid that can integrate into the bacterial

chromosome, acting like an episome.
These cells are called "Hfr cells" because they can transfer chromosomal DNA to

recipient cells more often than F+ cells.
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When Hfr cells connect with F-cells, they transfer a few chromosomal genes

along with a part of the F factor.
Usually, the connection between cells is broken before the entire genome is

transferred, so the recipient F- cells don't become F+ cells
F’ Conjugation
F+ cells can become Hfr cells, and this change can be reversed.

When the F factor goes back to being free, it can pick up some nearby chromosomal

DNA, creating what's called an F' factor or F prime factor.
When an F' factor conjugates with a recipient bacterial cell, it carries both the

F' factor and some host DNA into the recipient.
As a result, the recipient bacteria also become F' cells.

This whole process is known as sexduction.

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7. Write in detail about the laboratory diagnosis of viral infection. (10 Marks)
Answer:
Clinical Approach
Clinical Assessment- Begin with patient evaluation, considering symptoms and

medical history.
↓
Initial Tests- Perform initial tests like blood counts
↓
Serological Tests- If necessary, perform serological tests to detect specific antibodies
↓
Viral Load Measurement- Quantify viral load in specific infections (e.g., HIV, Hep-C).
↓
Imaging
↓
Specialized Tests- Consider specialized tests (e.g., PCR sequencing, viral genotyping)
↓
Confirmation- Confirm diagnosis by reviewing the clinical presentation and
laboratory results.
1. Direct Detection of Viruses
Electron Microscopy (EM): Negatively stained samples scanned by EM, identifying
viruses by their shapes (e.g., rabies virus-bullet-shaped, rotavirus - wheel-shaped).
Bullet Shaped Rabies Virus
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Wheel Shaped ROTA Virus

Direct Detection from Samples: Useful for challenging-to-culture viruses.
Virus Detection from Tissue Culture.
Immunoelectron Microscopy: Enhanced with specific antiviral antibodies.
Direct Immunofluorescence (Direct-IF): Detects viral particles in clinical samples.
Light Microscopy: Useful for inclusion bodies and immunoperoxidase staining.
2. Detection of Viral Antigens

Various assays, including ELISA, ICT, flow-through assays, ELFA, etc.
Notable tests for specific antigens (e.g., HBsAg, HBeAg, NS1, SARS-CoV-2
nucleocapsid protein).
3. Detection of Viral Antibodies
IgM antibodies indicate recent infection.
IgG antibodies, especially without recent elevation, suggest chronic or past infection.
Techniques like ELISA, ELFA, and ICT are commonly used.
4. Molecular Methods
More sensitive, specific, and rapid.
PCR for viral DNA (e.g., HSV DNA in CSF).
RT-PCR for RNA viruses (e.g., HIV RNA in blood).
Real-time PCR (rt-PCR) for various viral infections.
5. Isolation of Virus
Viruses are cultured in animals, embryonated eggs, or tissue culture.
Used for research purposes and diagnosing hard-to-cultivate viruses.
6. Animal Inoculation:
For research and primary isolation of specific viruses.
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7. Egg Inoculation:
The yolk sac, amnion, allantoic sac, and chorioallantoic membrane used for
different viruses.
8. Tissue Culture
Tissue Culture Description Examples
Organ Culture Used for viruses that Fastidious organ-specific viruses

prefer specific organs
Explant Cultures Tissue pieces (explants) Adenovirus adenoid explants
are grown in culture.
Monkey kidney cell line

(Primary; 5-10 division)
Human fibroblast cell line
Cell Line Culture
(Secondary; 15-20 division)
The most commonly used isolation method.
HeLa cell line, Hep-2
(Continuous; limitless division,
haploid)
Inclusion Bodies
Aggregates of viral proteins and genomic material inside host cells, altering staining
characteristics.
Types: Intracytoplasmic (e.g., Negri bodies, Guarnieri bodies) and intranuclear
(e.g., Cowdry Type A, Cowdry Type B).
Owl's Eye Appearance is associated with cytomegalovirus, measles virus, and more.
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Immunology
8. Write the difference between: (3 Marks)
(A) Primary and Secondary immune response?
(B) Active and Passive immunity?
Answer:
(A)
Primary immune response Secondary immune response
Immune response against first antigen Immune response against subsequent

encounter. antigenic exposure
Slow to appear and is short-lived Prompt, powerful and prolonged
The lag period is longer The lag period is absent or short
No negative phase A negative phase may occur
Antibody low titer and is of lgM type Antibody produced in high titer and is
of lgG type
Antibodies produced are less specific More specific
Antibody-producing cells- Naive B Antibody-producing cells- Memory B

cells cells
Both T-dependent and T-independent Only T-dependent antigens are
antigens are processed processed
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Immunology
(B) Active and passive immunity is used mainly in the sense of humoral immunity
in the form of antibodies.
Active immunity Passive immunity
Produced actively by the host immune Immunoglobulins received passively

system
Induced by: Infection (natural) and Acquired by: Mother to fetus lgG
Vaccination (artificial) transfer (natural) Readymade antibody
transfer(artificial)
Long-lasting Lasts for a short time
Lag period present No Lag period
Memory present No memory
Not useful in immunodeficient Useful in immunodeficient individuals

individuals
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9. What are the different types of antigens and adjuvants? Write in brief about
superantigens. (3 Marks)
Answer:
Antigen is any substance that has immunogenicity and antigenicity.
Immunogenicity is the ability to induce immune response both humoral and cell-
mediated.
Antigenicity is the ability to bind to specific products produced after the immune
response which is antibodies and TCR.
There are 2 classes of substances
Epitope- It is the smallest unit of antigen that initiates an immune response. The
site at which it binds with antibodies is known as paratrope.
Haptens- These are the substances that are antigenic i.e. they can bind to the
product of immune response but are no immunogenic i.e., they cannot initiate
an immune response on their own. They can become immunogenic if bound by a
larger molecule known as a carrier.
Adjuvant
These are substances that enhance the immunogenicity of an antigen. Examples
include alum, mineral oil, LPS
Mechanism of action of adjuvant
Delaying the release of antigens thus prolonging exposure.
Activates phagocytosis.
Activates Th cells.
Superantigens
These are a class of biological antigens that can activate T cells directly without
undergoing the process of antigen processing.
Superantigens take a shortcut; they don't need antigen-presenting cells to process
and present them.
Instead, they directly link the MHC class II molecule on antigen-presenting cells
to the T-cell receptor on T-cells. They do this by creating a bridge outside of the
usual binding sites.
This connection causes T-cells to activate without specificity, leading to the rapid
activation of a large number of T cells.
This, in turn, results in a massive release of cytokines.
Examples are staphylococcal and streptococcal toxins like TSST-1 and SPE-A
respectively
Diseases related to these superantigens are-
Toxic shock syndrome
Staphylococcal scalded skin syndrome (SSSS) etc.
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Immunology
10. Discuss in brief the structure of antibodies and the different classes of antibodies.
(10 Marks)
Answer:
Antibody is a glycoprotein produced by B cells in response to encountering an
antigen.
Structure
Antibodies are “Y-shaped” heterodimers composed of four polypeptide chains.
Two identical light (L) chains and two identical heavy (H) chains
(Source-Antibody basic unit.svg)

H and L chains
All four H and L chains are held together by disulfide bonds and non-covalent
interactions such as salt, hydrogen and hydrophobic bonds.
There are 5 classes of H chains and 2 classes of L chains here.
The five classes of H chains are structurally and antigenically distinct namely γ,
α, μ, δ, and ε each represents a class of antibody i.e. IgG, IgA, IgM, IgD and IgE
respectively.
There are two types of L chains. Kappa (κ) and Lambda (λ). In one antibody both
L are of the same type.
Variable and Constant Regions
Each heavy and light chain is composed of two regions, a variable region and a
constant region, depending on whether the regions exhibit a variable or uniform
pattern in antibodies with different amino acid sequences.
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Hypervariable regions, which represent the antigen-binding sites of antibodies:

Within the variable regions are several zones of relatively high variability in amino
acid sequence (hot spots) which form the antigen binding site.
Constant Region: Represents the rest of the Ig molecule that is not the variable
region.
Enzymatic Digestion
When an immunoglobulin molecule undergoes enzymatic digestion, various fragments

are formed
Papain Digestion: Papain cleaves Ig molecules at points above disulfide bonds in the
hinge region. This yields 3 fragments (crystallizable fragments)
Pepsin Digestion: Pepsin cleaves the Ig molecule at a point below the disulfide bond
in the hinge region. This forms one F(ab')2 fragment and many small fragments.
Mercaptoethanol digestion: separates H and L chains.
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Immunology
Characteristics Subclasses Functions
IgG IgG1, IgG2, IgG3, Crosses placenta

IgG4
Complement binding (classical
pathway)
Opsonization (enhances phagocytosis)
Mediates precipitation and

neutralization
Coagglutination (binds to Staph aureus
protein A)
IgM Exists in monomeric First antibody produced after infection
and pentameric
Complement fixation (strongest
forms
classical pathway activator)
B cell receptor for antigen binding
Easily recognized and removed once

bound to antigen
Protection from intravascular microbes
Mediates agglutination
IgA Monomeric and Antibody-dependent cell-mediated
dimeric forms cytotoxicity
Local/mucosal immunity
Secretory IgA rich in breast milk

Mediates type I hypersensitivity
reactions
IgE None known Elevated in helminthic infections
Stimulates eosinophil-mediated
cytotoxicity
IgD Functions as a B No other known functions
cell receptor
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11. Write a short note on the complement system (5 Marks)
Answer:
Complement is a group of proteins present in the serum in inactivated form and
once activated these augment the immune response of the body. It is a part of
both innate and acquired immune response
These are heat label proteins and if they get denatured this is called inactivated
serum.
Complement pathways
Pathway Trigger Key Feature
Classical Antigen-Antibody Relies on antibodies (IgG/IgM)

Complexes binding to antigens. Initiates cascade
leading to MAC formation.
Alternative Direct Interaction with Antibody-independent. Triggered by

Antigens pathogen surfaces (e.g., LPS). Begins
with spontaneous C3 hydrolysis
Lectin Mannose Binding Lectin Triggered by lectins recognizing

(e.g., MBL) sugar molecules on pathogens.
Activates complement cascade.
Steps of Complement Activation:
Initiation of pathways
Formation of C3 convertase
Formation of C5 convertase
Formation of membrane attack complex (MAC).
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Immunology
Complement system functions

Complement-Mediated Cytolysis (MAC Formation):
The Membrane Attack Complex (MAC) creates pores or channels in the target

cell membrane.
This allows ions and water to freely enter the cell, leading to cell swelling, lysis

(bursting), and ultimately, cell death.
This mechanism is effective against bacteria, enveloped viruses, damaged cells,

tumor cells, and other foreign or abnormal cells.
Inflammatory Response:
Complement components such as C3a, C4a, and C5a are known as anaphylatoxins.

They bind to mast cell surface receptors, triggering mast cell degranulation.

Mast cell degranulation releases histamine and other inflammatory mediators,

leading to:
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Vasoconstriction (narrowing of blood vessels).

Increased vascular permeability, allowing immune cells to access infection sites.

Opsonization:
Complement proteins C3b and C4b act as opsonins, enhancing phagocytosis.

They coat immune complexes and particulate antigens, making them more

recognizable to phagocytic cells.
C5a further boosts phagocytosis by increasing the expression of CR1 (Complement

Receptor-1) on phagocytes, improving their ability to engulf pathogens.
Clearance of Immune Complexes:
C3b plays a crucial role in clearing immune complexes from the bloodstream.

Immune complexes bound to C3b on red blood cells are transported to the liver

and spleen.
In the liver and spleen, they are separated from the red blood cells and

phagocytosed by immune cells.
Virus Neutralization:
The complement system is involved in neutralizing viruses.

Complement coating on the surface of viruses can block their binding sites and

reduce infectivity.
C3b-mediated opsonization of virus particles can mark them for phagocytosis.

Activation of the classical pathway can lead to the lysis of enveloped viruses.

These functions of the complement system are critical for the body’s defence against
infections, tissue damage, and the maintenance of overall immune homeostasis.
Clinical importance
Complement Protein Associated Disease

C1, C2, C3, C4 SLE
C3 Glomerulonephritis
MAC (Membrane Attack Complex) Increased susceptibility to infections from
encapsulated organisms (Neisseria etc.)
C1 Esterase Inhibitor Hereditary Angioedema (HAE)
Other Complement Regulatory Dysregulation of the complement system
Proteins leads to various diseases

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Immunology
12. What is the difference between (5 Marks)
(A) cell-mediated and humoral immune response?
(B) MHC class I and II?
(C) T-cell and B-cell?
Answer:
(A)
Humoral Immunity Cell-Mediated Immunity
Meaning It is associated with the It is associated with the

B-lymphocytes and is T Lymphocytes and is
responsible for destroying responsible for destroying
pathogens by producing the pathogens or
antibodies against them. microorganisms which have
invaded the cells.
Mediated by B-lymphocytes These are associated with

T lymphocytes, helper T
cells, natural killer cells and
macrophages.
Antibodies Present. Absent.
Function It plays a major role in Cell-mediated immunity is

recognising antigen or any related to T-lymphocytes,
foreign particle and in which work by identifying
producing antibodies against viruses and microorganisms,
it. thus destroying them
Humoral immunity is through cell lysis,
known for working against phagocytosis or pinocytosis.
extracellular pathogens. It is known for working
against intracellular
pathogens.
Secretes It secret antibodies. It secretes cytokines

Action against rapid or quick in response. show delay through
pathogens permanent response.
Hypersensitivity It involved in type I, II, III Type IV
Rejections Humoral immunity is Cell-mediated immunity is

involved in the early stage involved in the rejection of
of graft rejections due to the organ transplants.
formation of antibodies.
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(B)
MHC class I MHC class II

Present on All nucleated cells (except Antigen-presenting cells
sperm) and platelets (APCs)
Peptide antigen is Presented to CD8 T cells Presented to CD4T cells
Nature of peptide Endogenous or intracellular Exogenous

antigen (viral/ tumor antigen)
Antigen presentation Cytosolic pathway Endocytic pathway.
pathways
Peptide-binding site α1/α2 groove α1/β1 groove
(C)
Property T cell B cell

Origin Bone marrow Bone marrow
Maturation Thymus Bone marrow

Peripheral blood 70-80% of total lymphocytes 10-15% of total lymphocytes
Antigen recognition T cell receptors complexed B cell receptor-surface lgM
receptors with CD3 or lgD
CD markers CD 3,4, 8 CD19, 21, 24
Thymus specific Ag Present Absent
Microvilli on the Absent Present
surface

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Immunology
13. Write in brief about the body immune response against tubercular bacilli.
(5 Marks)
Answer:
Infection
with M.tuberculosis progresses stepwise from initial infection of
macrophages to Th1 response that involves the bacteria and causes tissue damage.
Stage of Immune Response Key Events/Processes
Infection with M.Tb Initial contact with Mycobacterium

tuberculosis (M.Tb).
Entry into Macrophages Phagocytosis of M.Tb by macrophages

through CR3 receptors.
Replication in Macrophages Inhibition of phagosome maturation and

phagolysosome formation. Recruitment
of host protein coronin to inhibit fusion.
Initial Innate Immune Response Recognition by TLR2 and TLR9, initiating

innate and adaptive immune responses.
Th1 Response Th1 cell activation is triggered by antigen

presentation and IL-12 production.
Th1-Mediated Macrophage Activation IFN-γ production, phagolysosome

maturation, iNOS, NO production, ROS
production, defensin production, and
autophagy activation.
Granulomatous Inflammation Formation of granulomas, giant
cell formation, TNF and chemokine
secretion. Some individuals experience
caseous necrosis.
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Reference: Pathologic Basis of Disease, Robbins and Cotran, 10th Edition, Page No. 368

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Immunology
14. Explain the various antigen-antibody reactions with examples of each.
(5 Marks)
Answer:
Antigen-antibody reaction is a biomolecular association in which these two combine

which is a specific observable manner without any change in the structure of the
antigen.
1. Precipitation Reaction
When a soluble antigen reacts with its antibody at optimal temperature, pH and in
the presence of an electrolyte (NaCl), an antigen-antibody complex is formed
Insoluble precipitation band-It is formed when this reaction takes place in a gels
or agar medium. This is known as immunodiffusion.
Insoluble floccules- When this reaction takes place in a liquid medium. This is
known as the flocculation test.
Examples.
Slide Flocculation test - Examples include the VDRL test and the RPR test for
syphilis.
Eleks Gel Precipitation Test- Detection of Diphtheria Toxin
2. Agglutination Reaction
When an insoluble antigen is mixed with its antibody at the appropriate temperature
and pH in the presence of electrolytes, the particles aggregate. Advantages: More
sensitive than sedimentation tests, and clumps are more visible and easier to
interpret.
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Types
Direct Agglutination Test
Type Description Examples

Slide Agglutination Used for confirming Identification of bacterial
bacterial identification, colonies, and blood grouping.
blood grouping, and cross-
matching.
Tube Agglutination Quantitative test to Widal test (Typhoid fever)
determine antibody levels Standard agglutination test
in serum, based on visible (Acute brucellosis)
agglutination. Weil-Felix reaction (Typhus
fever)
Paul-Bunnell test (Infectious
mononucleosis)
Microscopic agglutination
tests (e.g., for leptospirosis).
Indirect or Passive Agglutination Tests
Type Description Examples

Indirect Detects antibodies by Used for various antibody
Hemagglutination coating a soluble antigen detection purposes.
Assay (IHA) onto a carrier molecule’s
surface.
Antibodies bind to the

coated antigen, leading
to agglutination on the
carrier molecule.
Latex Agglutination Similar to IHA, used Commonly used for detecting
Assay (LAT) for antibody detection antibodies in various tests.
by coating antigens on
latex particles, leading
to agglutination when
antibodies are present.
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Immunology
Reverse passive agglutination test

This is done for antigen detection.
This test recognizes antigens in the patient's serum. Examples-Reverse Passive

Hemagglutination Assay (RPHA) for hepatitis B surface antigen (HBsAg).
3. Complement Fixation test

CFT detects antibodies in a patient's serum that can fix the complement. But now
almost obsolete.
Sabin-Feldmann dye test for Toxoplasma gondii.
4. Neutralization Tests
Neutralization tests are also less commonly used these days. Examples
Virus neutralization test: detects the presence of neutralizing antibodies in a
patient's serum.
Plaque inhibition test: This is done for bacteriophages Toxin–antitoxin neutralization
test like the Schick test for diphtheria, Nagler’s reaction for detection of α-toxin
of Clostridium perfringens
5. Enzyme-Linked Immunosorbent Assay (ELISA) ELISA is an immunoassay that

detects antigens or antibodies in a sample
Principle of ELISA
Immunosorbents -These specifically absorb antigens or antibodies present in serum.
Enzymes- to label one of the components i.e. antigen or antibody
Substrate-Chromogen System: Enzymes react with substrates and activate

chromogens to produce colour.
The color change is detected spectrophotometrically with an ELISA reader.
Color intensity is directly proportional to the amount of tracer molecule (Ag or

Ab) present in the test serum.
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ELISA is widely used nowadays to detect various antigens and antibodies.

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Immunology
15. (A) Write a short note on the rationale behind the vaccine and the types of
vaccine available with examples. (10 Marks)
(B) Differentiate between the various types of hypersensitivity reactions.
Answer:
Vaccines are a form of immunoprophylaxis that provides specific protection against
a given disease.
The rationale behind vaccine

Vaccines are based on the property of formation memory by the adaptive immune
system. When the body encounters an antigen for the 1st time weak primary
response is initiated but it also leads to the formation of memory cells.
On subsequent exposure stronger response is early generated due to memory cells
Vaccines work on this principle that they contain weakened pathogens or antigens
which induces the formation of memory cells so that when a pathogen enters, the
immune system mounts a strong response against it and it’s eliminated without
causing the disease.
(B) The various types of vaccines available are-
Live attenuated
These are prepared by making the organism attenuated i.e. making them lose
their ability to cause disease but retaining their immunogenicity.
These are very potent in inducing an immune response against all the major and
minor antigens and they also induce mucosal IgA production
They can cause infection in immunocompromised individuals there contraindicated
in them.
E.g.- BCG, MMR etc.
Killed vaccine
In this, the organism is grown in culture and killed using heat or formaldehyde
then injected to induce an immune response.
These are less potent therefore multiple doses have to be given and can also be
given in immunocompromised individuals.
The only contraindication is severe generalised or location reaction to the previous
dose
Eg-Typhoid vaccine, IPV, Rabies vaccine etc.
Toxoid vaccine
The exotoxins produced by certain bacteria are inactivated by treating with
formalin or acidic pH and then injected which induces an immune response against
only exotoxin.
E.g.- DT, TT etc.
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Subunit vaccine
Only the immunogenic component of the pathogen is isolated and then injected
to induce immunity.
E.g.- HBsAg for HBV, HPV vaccine.
Cellular fraction
The vaccine is prepared by extracting the cellular fragments of the virus of bacteria.
E.g.- meningococcal vaccine, pneumococcal vaccine.
Others
Vector-based, mRNA and recombinant vaccines.
COVID Vaccines
Vaccine Name Type

Covishield Viral Vector
Covaxin Inactivated Virus
Sputnik V Viral Vector

These 3 are approved for use in India.
Covaxin is an inactivated virus-based COVID-19 vaccine developed by Bharat

Biotech in collaboration with the Indian Council of Medical Research (ICMR)
Vaccines other than the above like Pfizer and Moderna are commonly used in the
US.
Vaccine Type Description Examples

Live Attenuated Weakened form of the live MMR, Yellow Fever, Oral Polio
virus or bacteria
Inactivated/Killed Virus or bacteria that has been Influenza, Polio (IPV), Hepatitis
killed or inactivated A, Covaxin
Subunit/Protein Contains only specific pieces of HPV, Hepatitis B, Pertussis
the pathogen
Toxoid Inactivated toxins produced Diphtheria, Tetanus
by bacteria
mRNA Uses genetic material (mRNA) Pfizer, Moderna
to trigger an immune response
Vector-based Uses a harmless virus or vector Johnson & Johnson (Janssen)
to carry pathogen genes Covishield
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Immunology
DNA Contains a piece of the Not widely used

pathogen's DNA
Recombinant Created by genetic engineering Recombinant Hepatitis B,
Rotavirus
(B)
Hypersensitivity is the exaggerated immune response to a foreign or self-antigen
which leads to tissue destruction and inflammation of the normal body tissue
Type I Type II Type III Type IV

Immune Humoral Humoral Humoral Cell-mediated
response
involved
Time taken Within minutes Within 6 hours Within 10 Delayed 24-
to hours hours 72 hours
Mediator Soluble lgE Cell surface- Soluble IgG T cells
bound lgG and
IgM
Effector Mast cell ADCC and Ag-Ab CD 8+
mechanism degranulation Complement complex cells cause
mediated deposits in Macrophage
cytolysis various organs activation
initiate an which leads to
immune phagocytosis
response
Typical Anaphylaxis Hemolytic SLE Contact
manifestations anemia dermatitis

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Hospital Infection Control
16. Write in brief about the different coloured bins in biomedical waste management.
(3 Marks)
Answer:
Treatment/
Category Type of waste Type of bag
Disposal
Yellow Infected anatomical Yellow non- Incineration/
waste of both humans chlorinated plastic pyrolysis
and animals like samples, bag
biopsies etc.
Chemotherapy drugs.
Microbiology and other
clinical lab nonplastic
waste
Red Infectious plastic waste Red non- Autoclave/
like urinary catheters, chlorinated plastic hydroclave
drainage tubes, syringes bag
Mutilation
without needles, gloves
etc.
White Sharps Puncture proof, Autoclave followed
(translucent) leak proof, by shredding
Needle, blades, scalpel etc.
tamper proof
container.
Blue Glassware like Puncture-proof, Disinfection by
vials,beakers, slides leak-proof chemical method
container or by autoclave/
Implants like dental
hydroclave then
implants etc.
recycling.

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17. (1) You are an intern posted in the surgery ward. You are taking blood samples
of the patients admitted and during recapping you get yourself pricked by
the needle.
(A) What is this case of?
(B) How will you manage?
(C) What precautions to be taken to prevent this?
(2) What is the Spaulding classification? (5 Marks)
Answer:
1. (A) This is a case of needle stick injury (NSI).
(B) There are 9 important steps that one should follow if he/she gets an NSI-
1. First Aid: First aid should be started as soon as possible

2. Report to nodal officer: The node centre performs the functions(steps 3-9)
3. Take the first dose of PEP for HIV: The first dose of PEP for HIV should be
taken as early as possible. The effect is maximum if taken within 2 hours and
no effect if taken after 72 hours of exposure.
NACO recommends - 5 tablets on 1st day of exposure.
Tenofovir 300 mg + Lamivudine 300 mg, one tablet once daily
Lopinavir (200 mg) + Ritonavir (50 mg) two tablets twice daily.
4. BBV Tests: The following tests should be performed for both Source and
HCW-
Anti-HIV antibody
HBsAg
Anti-HCV antibody
Anti-HBV antibody
5. Make decisions regarding post: exposure prophylaxis (PEP) for HIV and HBV
based on standard guidelines (NACO for HIV and CDC for HBV)
6. Informed Consent and Counseling: Almost everyone feels anxious after being
exposed. They should be given advice and psychological support.
7. Documentation of the exposure and consent form should be filled out for PEP
treatment.
8. Follow-up testing:
HIV- at 6 weeks, 3 months and 6 months following exposure.
HBV and HCV - at 6 months following exposure
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9. Precautions during the follow-up period:

Avoid donating blood/semen/organ/plasma.
Avoid sexual intercourse
Avoid breastfeeding
1. Precautions to prevent NSI are:
Preventive Measure Description
Safe Needle Handling Use safe techniques when handling

needles.
Do not recap needles with both hands.
Avoid using excessive force during

disposal.
Proper Disposal Immediately dispose of needles and

sharps in designated containers.
Education and Training Ensure healthcare workers receive

training on safe needle handling.
Personal Protective Equipment (PPE) Wear appropriate PPE like gloves and
eye protection.
Hand Hygiene Practice thorough hand hygiene before

and after needle handling.
Use soap and water or hand sanitizer
Needle Recapping Use safe methods for recapping needles
2. Spaulding classification- It is used to classify medical devices into three categories

by the risk of infection by use of these items.
Recommended Medical equipment

Risk category Definition
method or surfaces
Critical device Items that enter a Sterilisation Surgical
normally sterile site instruments,
(high risk)
implants/
prostheses, rigid
endoscopes,
syringes, needles
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Semi-critical Items in contact Disinfection Respiratory

device(intermediate with mucous (HLD) equipment, non-
risk) membranes or body invasive flexible
fluids endoscopes,
bedpans, urine
bottles Non-critical
patient items
Non-critical (low-risk) Items in contact Disinfection Non-critical
with intact skin (ILD or LLD) environmental
surfaces

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CVS
18. Write in brief about spirochetes and explain the Features and diagnosis of Lyme
disease. (3 Marks)
Answer:
Spirochetes are gram-negative, spirally coiled, thin, helical bacilli.
3 main pathogens of this group cause infections in humans:-
Treponema

Borrelia

Leptospira

They have an endoflagella responsible for motility.
It exhibits various types of motility like flexion-extension, corkscrew and translators
movements.
These are differentiated based on the no. Spirals and length of bacilli.
Bacteria Length No. of spirals Disease caused
Treponema Smallest 6 to12 Syphilis, Yaws,

Pinta etc.
Leptospira Intermediate Numerous Weils disease
Borrelia Largest 3 to10 Lyme disease,

Vincent angina etc.
To visualize them
Dark-Field Microscopy: Use this technique for live, unstained spirochete observation.
It illuminates the spirochetes against a dark background.
Silver Staining: Employ this method for fixed tissue or clinical samples. It binds
silver to spirochetes, making them visible under a microscope, and aiding in disease
diagnosis.
These techniques are crucial for identifying spirochete-related diseases like syphilis and Lyme
disease.
Lyme disease
It is caused by Borrelia burgdorferi which is transmitted by the bite of Ixodes tick.
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CVS
Clinical manifestations
Stage Description
Stage 1 Initial Local Infection
Erythema migrans, a ring-shaped maculopapular

lesion, develops at the site of the tick bite.
Stage 2 Initial Disseminated Infection
Hematogenous spread of Borrelia burgdorferi to

multiple sites
Secondary annular skin lesions.
Symptoms include joint pain, malaise, and

neurological abnormalities.
Stage 3 Late Persistent Infection (Lyme Arthritis)
Patients develop arthritis, primarily affecting

large joints like knees.
The arthritis can persist for several months.
Laboratory tests
Isolation: From culturing samples such as skin lesions, blood and cerebrospinal fluid
in a special medium called his BSK medium (Barbour-Stoenner-Kelly).
Molecular methods: PCR to detect specific DNA is more sensitive in synovial fluid.
Antibody detection: By ELISA if positive confirm by western blot.
Non-specific findings like leukocytosis in synovial fluid.
Treatment
Oral doxycycline in adults for 14 days in skin lesions and 1-2 months in cases of
arthritis.
If CNS is involved- Ceftriaxone.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat, 3rd Edition,
Page No. 319

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19. Write a short note on leptospirosis. (3 Marks)
Answer:
Causative Agent: Leptospira interrogans causes leptospirosis or Weil's disease.
Transmission
It's a zoonotic disease with no direct human-to-human transmission.
Infection occurs through indirect contact with contaminated water, soil, or

surfaces with animal urine, or direct contact with infected animal urine, offspring,
or placenta.
Epidemiological Determinants: The "3Rs" for leptospirosis are exposure to rodents,

rainfall, and rice fields.
Pathogenesis
Stage 1(Septic) Spirochetes enter through mucous membranes

or abraded skin.
Hematogenous spread to various organs.
Causes vascular injury with active motility and
hyaluronidase
Stage 2(Immune) Antibody development clears spirochetes from

the blood.
Antigen-antibody complexes deposited in
various organs
Clinical Manifestations
Two clinical syndromes:
Mild Anicteric Fever Disease: Includes symptoms like nausea, vomiting, abdominal

pain, and muscle aches.
Weil's Disease (Hepatorenal Hemorrhagic Syndrome): Occurs in 10% of patients

and involves severe jaundice.
Laboratory Diagnosis
Specimen: CSF, blood (1-10 days), and urine (10-30 days after infection).
Microscopy: Leptospira is very thin and visible on dark ground or under a phase-
contrast microscope, displaying rotational and translational motion. They can be
stained by silver impregnation.
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CVS
Culture Isolation: Leptospira are obligatory aerobic and slow-growing. Media used
include EMJH liquid medium, Korthof's medium, and Fletcher's semi-solid medium.
Antibody Detection: IgM antibodies appear early within 1 week of symptom onset,
peaking at 3-4 weeks, while IgG appears later. They are detected by ELISA and
Lepto Dipstick assay, Microscopic Agglutination Test (MAT).
Molecular Diagnosis: PCR techniques targeting 16S or 23 rRNA.

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20. Explain the clinical features and laboratory diagnosis of Brucella. (3 Marks)
Answer:
Brucella causes brucellosis
It is a gram-negative obligate aerobic cocco-bacilli.
Pathogenesis
B. melitensis is the most pathogenic species, followed by B. abortus.
Transmission: Brucellosis is a zoonotic disease
Direct contact

Food-borne

Spread of disease: From the initial site of infection into the bloodstream, causing
bacteremia and then spreading to various organs.
Organs involved: Brucella primarily infects organs of the reticuloendothelial system
Local tissue reactions: First, there is an infiltration of neutrophils. They are then
replaced by chronic inflammatory cells, leading to granuloma formation.
The incubation period varies from 1 week to several months
Classic triad: Fever with profuse night sweats, arthralgia/arthritis and

hepatosplenomegaly.
Foul-smelling perspiration
Overall brucellosis resembles a typhoid-like illness except that it is less acute,

and less severe with an undulating pattern of fever and more musculoskeletal
symptoms
Undulating fever: Fever has a typical remittent course, i.e. in between febrile
periods (which last for weeks), there will be afebrile periods. It is also called Malta
fever or Mediterranean fever
Complications
Vertebral osteomyelitis
Septic arthritis
CNS: Depression and lethargy with meningitis or lymphocytic meningoencephalitis.
CVS: Rarely causes endocarditis
Genitourinary manifestations: Include acute epididymo-orchitis, prostatitis,

salpingitis and pyelonephritis.
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CVS
Laboratory Diagnosis of Brucellosis

1. Culture:
Brucella can be cultured from blood, bone marrow, synovial fluid, or other tissues.
Culture Conditions: Strict aerobes, but growth is enhanced in the presence of

5-10% CO2.
On blood agar, small non-hemolytic transparent colonies are observed.
Identification: Small, unencapsulated Gram-negative cocci.
Brucella is non-motile in the hanging test.
Positive for catalase and oxidase.
2. Serological Testing (Antibody Detection):

Standard Agglutination Test (SAT):
Considered the gold standard for serology.

SAT recognizes whole antibodies (IgM + IgG) and cannot distinguish between

acute and chronic infections.
2-Mercaptoethanol (2ME) SAT Test:
2ME destroys IgM antibodies.

SAT performed on 2ME-treated sera:

SAT positive, 2ME-SAT negative: Indicates acute brucellosis (IgM).

SAT positive, 2ME-SAT positive: Indicates chronic brucellosis (IgG).

ELISA
Dipstick Test:
3. Molecular Methods:
PCR
Treatment
Gentamicin for 7 days with doxycycline for 6 weeks.

ASHISH47 SEHRA
21. Write in brief about chikungunya. (3 Marks)
Answer:
Chikungunya is a relapsing disease characterized by acute fever with severe joint
pain.
It belongs to the family Togaviridae of the genus Alphavirus. It is an enveloped
virus containing ssRNA.
Transmission
Aedes aegypti, which bites during the day
Vertical transmission from mother to fetus, rarely occurs through blood transfusions
or organ transplants.
Transmission cycles: The Chikungunya virus persists in the environment through
urban cycles (between humans and Aedes aegypti) and forest/jungle cycles (between
monkeys and the forest species Aedes aegypti).
Clinical Symptoms
The incubation period is approximately 5 days.

Acute phase: The most common symptoms are fever and severe joint pain (due to
arthritis), which is worse in the morning. Arthritis is polyarticular, mobile, and
edematous (swelling of the joints), primarily affecting the small joints of the wrists
and ankles.
Other symptoms include headaches, muscle pain, tendonitis, or an umbilical skin
rash. This symptom is often confused with that of dengue fever.
Chik sign (brownie nose appearance): characterized by hyperpigmentation over
the centrofacial area; occurs due to increased intraepidermal melanin retention
triggered by the chikungunya virus.
Chronic stage: Persistent joint pain.
Laboratory diagnosis
Viral isolation in mosquito cell lines (takes 1–2 weeks) is useful for early diagnosis
(0–7 days),
Serum antibody detection: IgM appears after 4 days of infection and lasts for 3
months; IgG appears late (after 2 weeks) and lasts for years. So, detection of IgM
or a fourfold rise in IgG titer is more significant MAC (IgM Antibody Capture)
ELISA is the best format available
Molecular methods: Reverse transcriptase PCR was developed to detect specific
genes (NSP1, NSP4, etc.) in blood.
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CVS
Hematologic findings:
Primarily leukopenia with high lymphocyte count,

Thrombocytopenia (rarely)

Increased ESR and CRP.

Treatment
Supportive care.

ASHISH49 SEHRA
22. Write a short note on Dengue virus. (5 Marks)
Answer:
Dengue virus belongs to the family Flaviviridae.
It is an enveloped ssRNA virus.
It has 5 serotypes DEN1 to DEN5
Vector
Aedes aegypti and aedes albopictus (usually bites during day time)
Natural course of Disease
Primary Dengue Infection

↓
Infection with any serotype of Dengue Virus
↓
Months to years later, development of secondary Dengue Infection (more severe)
↓
Infection with a different serotype from the first serotype that caused the primary
infection
↓
Antibody Response to Dengue Virus
↓
Production of neutralizing and non-neutralizing antibodies
↓
Neutralizing antibodies protect against both infectious serotypes (persist for life)
↓
Non-neutralizing antibodies, heterotypic in nature, last lifelong and are produced
against other serotypes
↓
Antibodies from the first serotype infection can bind to a second serotype during
secondary dengue infection
↓
Instead of neutralizing the second serotype, they protect it from the host immune
system by inhibiting bystander B cell activation against the second serotype
↓
This phenomenon is known as Antibody-Dependent Enhancement(ADE)
↓
ADE is significantly observed when serotype 1 infection is followed by serotype 2,
which is the most severe form of dengue infection.
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CVS
Dengue Clinical Stages

Dengue Fever (DF):
Abrupt onset of high fever (biphasic fever, break bone fever, saddle back fever)
Maculopapular rashes over the chest and upper limbs
Severe frontal headache
Muscle and joint pains
Lymphadenopathy
Retro-orbital pain
Loss of appetite, nausea, and vomiting
Dengue Hemorrhagic Fever (DHF)

Severe and persistent fever
Hepatomegaly
Thrombocytopenia
Spontaneous bleeding from the skin, nose, mouth, or gums
Dengue Shock Syndrome (DSS)

Symptoms of DHF along with shock
Fast and weak pulse
Low pulse pressure
Dengue Fever during Pregnancy

Perinatal transmission of dengue infection can occur.
Laboratory Diagnosis of Dengue

1. NS-1 Detection:
Early Detection: NS-1 antigen detectable from the first day of fever.
2. Antibody Detection:(MAC-ELISA antibody capture)

Primary Infection: Slow and low titer IgM response, appears after 5 days, disappears
within 90 days.
IgG Detection: Low titers 14-21 days after onset, increase slowly.
3. Rapid Diagnostic Test (ICT):

Available for quick diagnosis.
4. Virus Isolation- Not routinely done
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5. Molecular Methods
Real-time RT-PCR for detecting specific genes in viral RNA.
Most sensitive and specific assay for serotype detection and quantification.
Treatment
Treatment is symptomatic and supportive, including replacement of plasma loss,
correction of electrolyte and metabolic disturbances, and platelet transfusions as
needed.
Prevention
Dengue vaccine
Mosquito repellants, anti larval measures.

ASHISH52 SEHRA
CVS
23. Write in brief about the Ebola virus. (3 Marks)
Answer:
Ebola virus belongs to the family Filoviridae. These are pleomorphic filamentous
viruses. It has a very high mortality rate.
Transmission
Ebola virus is introduced to the human population through close contact with
the blood, secretions, organs or other body fluids of infected animals such as
chimpanzees, gorillas, fruit bats or monkeys.
Human-to-human transmission: Once introduced to humans, Ebola virus spreads
among people via
Direct contact- Blood, secretions, organs or other bodily fluids of infected people
Infected surfaces and materials
Incubation period is about 2–12 days

Common symptoms include fever, headache, muscle pain and sore throat,
Abdominal pain, vomiting and severe watery diarrhoea
Diffuse erythematous maculopapular rash, petechiae, and ecchymosis/bruising,
often leading to shock and death.
Mortality: Average mortality is approximately 50%.
Serum Antibody Detection: ELISA employs recombinant nucleoprotein (NP) and
glycoprotein (GP) antigens for the separate detection of IgM and IgG antibodies
in the serum.
IgM occurs 7 days after symptoms begin and lasts for 3 to 6 months.
IgG appears after 2 weeks and persists for 3-5 years or more.
Serum antigens are detected by capturing ELISA.Target proteins are NP, VP40,
and GP.
Immunohistochemical staining and histopathology can also be used to localize
Ebola virus antigens within tissues.
Molecular methods such as RT-PCR and real-time RT-PCR
Electron microscopy of a sample shows a typical filamentous virus
Virus isolation in Vero cell lines
Treatment
Supportive measures such as hydration and symptomatic treatment improve
survival.

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24. Write in brief about the classification of rickettsia and clinical features and
laboratory diagnosis of Rocky Mountain spotted fever. (5 Marks)
Answer:
Rickettsia are a group of non-motile gram-negative coccobacillus which have
certain characteristics different from other bacteria -
Obligate intracellular

Grown on cell lines and not in culture media

Transmitted by arthropods

They infect endothelial cells lining the blood vessels.

Because of these reasons they were earlier considered as a virus but now they are
included in bacteria.
Bacteria Disease Vector Rash Eschar

Epidemic typhus R. prowazekii Louse 80% (All over the body -
except palm and sole)
Endemic typhus R. typhi Flea 80% (trunk) -
RMSF R. rickettsii Tick 90%(extremities and trunk, Rare

more hemorrhagic)
Indian tick typhus R. conorii Tick >95% +

(ITT)
African tick bite R. africae Tick 50% (vesicular) ++
fever
Rickettsialpox R. akari Mite 100% (vesicular) ++
Scrub typhus Orientia Mite 50% +

tsutsugamushi
Rocky Mountain spotted fever

RMSF is caused by Rickettsia rickettsii.
Infection: By infected tick
Incubation period - 4-14 days.
RMS fever is an acute, potentially fatal illness characterized by fever, headache,

rash, myalgia, and loss of appetite.
The rash usually appears on the extremities(wrists, ankles, etc.) and trunk. At first
maculopapular, later hemorrhagic.
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Complications
Vascular injury, increased permeability, edema, haemorrhage
DIC, interstitial pneumonitis
CNS involvement
Specimen collection-Whole blood, buffy coat fraction, pores and skin rash biopsies,
lymph node biopsies or tissue specimen
Antibody detection-
Weil-Felix test - The antibodies produced against the LPS antigen of rickettsia

are heterophile in nature i.e. these antibodies also react with antigen of some
other bacteria like Proteus. So it’s a heterophile agglutination test. It is non-
specific but cheap so widely used. For RMSF it has antibodies elevated for OX19
and OX2.
Disease OX-2 OX-19 OX-K

Epidemic typhus +/- ++++ -
Endemic typhus +/- ++++ -
RMSF ++ ++ -
Scrub typhus - - ++
Specific antibody detection by IFA- Appear a week after infection

ELISA

Histological exam-cutaneous biopsy pattern from a rash lesion

Isolation-On cell lines Vero and HeLa, egg yolk sac inoculation, or animal inoculation
Neil-Mooser reaction: It is a form of animal pathogenicity test. By this, we can

also identify species of the bacteria.
Molecular tests: PCR and real-time PCR
Treatment: Doxycycline for 5 days is the drug of choice.


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25. Write a short note on scrub typhus? (3 Marks)
Answer:
Scrub typhus is caused by Orientia tsutsugamushi
Transmission: It is transmitted by trombiculid mite. The larvae of the mite is only

stage that act as a vector therefore it is also known as chiggerosis.
Mites can acquire organisms by transovarial transmission.
The typical presentation of typhus fever consists of a triad of eschar (at bite site),
local lymphadenopathy, and maculopapular rash.
Non-specific symptoms such as fever, headache, muscle aches, cough and
gastrointestinal symptoms may appear early.
Complications
Encephalitis
Interstitial pneumonia
The zoonotic tetrad: Four elements are essential to the maintenance of O. tsutsugamushi in
nature
Trombiculid mite
Small mammals
Scrub vegetation
Wet season (dusting this time mites lay eggs)
1. Serology (Detection of Antibodies)
In a primary infection, IgM antibodies typically show up around the end of the
first week, while IgG antibodies appear by the end of the second week.
During reinfection, IgG antibodies can be detected as early as day 6, and the levels
of IgM antibodies may fluctuate.
Weil-Felix Test: Detects non-specific, high-titer heterophile antibodies to Proteus
OX-K antigen.
Indirect Immunofluorescent Antibody (IFA): the gold standard for serological
testing.
ELISA
2. Molecular Assays- PCR
3. Isolation of bacteria- HeLa cell lines are used to grow and isolate the pathogen.
Treatment : Doxycycline is the DOC.

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CVS
26. Write in brief about TPE. (3 Marks)
Answer:
Tropical Pulmonary Eosinophilia (TPE)

A rare syndrome occurring in individuals infected with the filarial parasites

Wuchereria bancrofti or Brugia malayi.
Commonly found in endemic areas and is also referred to as subclinical filariasis

or Weingarten syndrome.
Etiopathology
TPE results from a hypersensitivity reaction to antigens produced by microfilariae,

the larval stage of filarial parasites.
Microfilariae, once released into the bloodstream, are swiftly removed and

filtered in the pulmonary capillaries, leading them to be trapped in the lungs.
In the lungs, these microfilariae cause an immune response, leading to allergic

reactions and the characteristic symptoms of TPE.
Interestingly, microfilariae are not typically detected in peripheral blood samples.

Clinical Features
Patients with TPE commonly present with:
Nocturnal paroxysmal cough.

Wheezing.

Weight loss.

Low-grade fever.

In some cases, microfilariae can migrate and become trapped in other organs,
including the spleen, liver, and lymph nodes.
This can result in:
Hepatosplenomegaly (enlargement of the liver and spleen).

Lymphadenopathy (enlarged lymph nodes).

The combination of these organ-related symptoms is sometimes referred to as

Myers-Cowenaar syndrome.
TPE tends to affect males more frequently than females, with a higher incidence
observed in the third decade of life.
Blood eosinophilia: Characterized by an absolute eosinophil count greater than

3000 eosinophils per microliter (µL) of blood.
Chest X-ray: Typically shows diffuse infiltration of the lung parenchyma.

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Pulmonary function tests: Often reveal obstructive changes in the lungs, reflecting

the airway involvement in this condition.
Treatment
Diethylcarbamazine (DEC) is the primary treatment for TPE.

Typically administered at a dosage of 4–6 mg/kg of body weight for a duration

of 14 days.
DEC is effective in eliminating microfilariae and relieving the associated symptoms

of TPE.
Reference: Essentials of Medical Microbiology, Apurba S Sastry and Sandhya Bhat,

3rd Edition, Page No. 677
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CVS
27. Write a short note on systemic mycoses with laboratory diagnosis. (5 Marks)
Answer:
Systemic mycoses involve a group of fungi that initially infect lungs by spore
inhalation and from there disseminate to various organs via a hematogenous route.
These are mainly:

Histoplasma capsulatum causing histoplasmosis
Blastomyces dermatitidis causing blastomycosis
Coccidioides immitis causing Coccidioidomycosis
Paracoccidioides brasiliensis causing Paracoccidioidomycosis
These all are saprophytic, dimorphic fungi i.e. they exist in 2 morphological forms
based on temperature. Heat at 37 C and mold at 25 C.
The most common infection among these is histoplasmosis.
Histoplasmosis
Pathogenesis
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Clinical Features
Pulmonary histoplasmosis: The acute form is manifested by mild flu-like illness,
and pulmonary infiltrates with hilar or mediastinal lymphadenopathy on chest
radiographs.
Chronic cavitary histoplasmosis may be seen in smokers with underlying structural
lung disease.
Mucocutaneous histoplasmosis: Skin and oral mucosal lesions may occur as a result
of pulmonary infection. Oral lesions are particularly common in Indian patients
Disseminated histoplasmosis: The most commonly affected sites are the bone
marrow, spleen, liver, eyes, and adrenal glands.
Diagnostics
Specimens collection: include sputum, bone marrow and lymph node aspirates,
blood, skin and mucosal biopsies.
Direct microscopy: Histopathological staining of specimens (such as PAS, Giemsa,
or GMS staining) reveals small oval yeast cells with narrow base budding within
macrophages,
Culture: This is the gold standard diagnostic method. Specimens should be inoculated
onto media such as SDA, blood agar or BHI agar and incubated simultaneously at
25°C and 37°C.
Histoplasma is a dimorphic fungus so-

At 25° C - Tuberculate macroconidia
At 37° C - creamy white yeast colonies seen
Antibody detection - CFT and immunodiffusion test.
Skin test - Delayed type hypersensitivity reaction to histoplasmosis antigen.
Molecular test - PCR to detect 28S rRNA.
Treatment
Supportive therapy for mild disease
Oral itraconazole for chronic cavitation
IV amphotericin B/liposomal followed by oral itraconazole for severe pulmonary

or disseminated disease
Blastomycosis
Pathogen: Blastomyces dermatitidis
Risk Factors:
Travel to the Southeastern, Central, Eastern, and Great Lakes regions of the

United States
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Clinical Features:
Pneumonia

Extrapulmonary findings: skin (verrucous lesions and granulomatous nodules),

bone (osteolytic lesions), genitourinary involvement, CNS lesions
Diagnostics:
KOH or culture (sputum, urine, body fluids)

Yeast form (at body temperature): broad-based buds

Mold form (at room temperature): circular fungal cells with filamentous hyphae

Treatment:
Fluconazole and itraconazole for local infection

IV amphotericin B for systemic infection

Coccidioidomycosis
Pathogen: Coccidioides immitis, Coccidioides posadasii
Risk Factors:
Travel to Southwestern United States, California

Clinical Features:
Flu-like illness or pneumonia with fever, cough, night sweats, anorexia, chest

pain, and dyspnea
Extrapulmonary findings: CNS (meningitis), skin (erythema nodosum), joints

(arthralgia), bone (multiple osteolytic lesions)
Diagnostics:
Serology (Increased IgM at onset, IgG later)

Chest x-ray

KOH, silver stain, or culture (sputum, wound exudate, joint effusion)

Large spherules containing endospores

Treatment:
IV amphotericin B for severe infection

Itraconazole as an alternative

Paracoccidioidomycosis
Pathogen: Paracoccidioides species (Paracoccidioides brasiliensis, Paracoccidioides
lutzii)
Risk Factors:
Travel to South and Central America

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Clinical Features:
Often asymptomatic

Painful nasal, pharyngeal, and laryngeal mucosal ulcerations

Lymphadenopathy (usually cervical)

Extrapulmonary manifestations, including verrucous skin lesions similar to those

of cutaneous blastomycosis
Diagnostics:
KOH/calcofluor staining on smears or silver/PAS staining on tissue biopsy

Budding yeast with "captain's wheel" formation

Treatment:
Itraconazole in most cases

IV amphotericin B for severe or refractory cases


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CVS
28. A 42-year-old man complained of fever, and fatigue. He recently had a tooth
extraction 2 weeks ago. He reported feeling generally unwell, with a low-grade
fever that had persisted for the past week. On physical examination, a heart
murmur was detected. The doctor made the diagnosis of IE. (10 Marks)
(A) What are the common causes of Infective endocarditis and the laboratory
diagnosis?
(B) Write in brief about Fever of unknown origin.
(C) What are the hospital-associated bloodstream infection?
(D) List 3 infective causes of anemia.
Answer:
(A) IE or infective endocarditis is the infection of the endocardium of the heart
characterized by the formation of bulky friable vegetation
Etiological agents of IE are-

Staphylococcus aureus
CoNS
Streptococci (viridans streptococci and others)
Pneumococci
HACEK group-
Haemophilus parainfluenza

Aggregatibacter species

Cardiobacterium hominins

Eikenella corrodens

Kingella kingae.

Rarely by Coxiella burnetii.
Acute endocarditis Subacute endocarditis
Evolution is rapid Evolution is slow
Involves normal cardiac valve Involves previously damaged heart or valve
High virulence, e.g. S. aureus Low virulence, e.g. viridans streptococci
Causes substantial morbidity and Patients recover after antibiotic therapy

mortality
Less common More common
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Diagnosed using Modified Duke’s criteria
Major Criteria Description
Typical IE organisms isolated from two

separate blood cultures
Persistently positive blood culture with
agents other than typical IE organisms
Blood culture sets drawn > 12 h apart; or
Positive blood culture all of 3 sets or a majority of 24 separate
blood cultures, with the first and last
drawn at least 1 h apart
Single positive blood culture for Coxiella
burnetii or phase 1 lgG antibody titer of
> 1:800
Positive echocardiogram
Oscillating intracardiac mass on valve or

Evidence of endocardial involvement abscess
New partial dehiscence of prosthetic valve
New valvular regurgitation
Minor Criteria Description
Predisposing heart conditions or IV drug

Predisposition
use
Fever > 38.0°C Fever above 38.0°C (100.4°F)
Major arterial emboli
Septic pulmonary infarcts
Mycotic aneurysm
Vascular phenomena
Intracranial hemorrhage
Conjunctival hemorrhages or Janeway

lesions
Glomerulonephritis
Osler’s nodes
Immunologic phenomenon
Roth’s spots
Rheumatoid factor
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CVS
Positive blood culture but not meeting

major criterion as noted previously
Microbiologic evidence Serologic evidence of active infection with
an organism consistent with infective
endocarditis
Definite endocarditis can be diagnosed if the following criteria are met:
Two major criteria
One major criterion and three minor criteria
Five minor criteria
(B) Fever of unknown origin: It is implied to be a febrile illness without any initial
obvious etiology.
Definition
Fever ≥38.3°C on at least two occasions
Duration of illness of ≥3 weeks
No known immunocompromised state
Diagnosis that remains uncertain after a thorough history-taking, physical

examination, and the following obligatory investigations:
ESR and CRP (C-reactive protein)

CBC

Electrolytes, creatinine, total protein, ferritin

protein electrophoresis

ALP, AST, ALT, LDH, creatine kinase

ANA and RF

Urinalysis

Culture: blood cultures (3 negative cultures) and urine culture

Radiology: Chest X-ray, abdominal USG

Tuberculin skin test or interferon-gamma release assay.

Causes of FUO
Infectious- like TB, rickettsia, typhoid, Histoplasma
Neoplastic- Leukemia or any other underlying malignancy
Autoimmune- SLE, sarcoidosis, rheumatoid arthritis etc.
Miscellaneous- inherited and metabolic diseases, granulomatous conditions etc.
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(C) Hospital-associated bloodstream infections are CRBSI or catheter related

bloodstream infection
Causative agents are
Klebsiella, enterobacter, and pseudomonas commonly in intrinsic contamination

CoNS, Staph aureus commonly in extrinsic contamination.

(D) Infective causes of anemia
Hemolytic
IDA Megaloblastic Aplastic
Anemia
Hookworm Malaria Diphyllobothrium Leishmania
infestations like latum- This donovani
Clostridium
Ancyclostoma and worm dissociates
perfringens EBV and
Necator americanus B12 and intrinsic
CMV
Mycoplasma factor complex
Trichuris trichura
pneumoniae thus B12 cannot Parvovirus
Schistosoma be absorbed. B19
Rickettsia
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CVS
29. A 32-year-old male patient presents with a three-month history of fatigue, night
sweats, and a weight loss of 10 kg. He denies any recent travel or sick contacts.
Reports engaging in unprotected sexual intercourse with multiple partners,
including casual encounters, over the past year. Oral thrush (candidiasis) present
in examination. Lab tests show a decreased CD4+ count and antibodies for HIV
are positive. (10 Marks)
(A) Draw a labeled diagram of HIV.
(B) Write the Pathogenesis of HIV.
(C) Clinical features of HIV and Laboratory diagnosis of HIV?
(D) NACO strategy algorithms for HIV?
(E) Enumerate the common opportunistic infection occurring in HIV.
Answer:
(A)
1. env gene codes for envelope protein which has 2 important components
gp120- receptor that binds to T-cells
gp41- fusion protein
2. pol gene codes for viral enzymes

p31 for integrate
p51 for reverse transcriptase
3. gag gene codes for core and shell proteins of the virus particle
p18- matrix antigen
p24- core antigen
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(B) Mode of transmission

Blood transfusions- It has more than 90% risk of transmission but no. of cases due
to this is only 1% because of stringent screening.
Verticle (from mother to fetus)-moderate risk
Sexual intercourse- least risk of around 0.1 to 1% but contributes most to the no.
of cases (anal intercourse has a higher risk of transmission than vaginal)
Other methods like sharing IV drug needles, NSI etc.
Pathogenesis
Major Receptor: HIV binds to CD4 receptor on host cell surface

↓
Attachment of a second coreceptor (CXCR4 or CCR5) to gp120
↓
Fusion: Mediated by gp41, HIV fuses with host cell
↓
Penetration and Uncoating: HIV nucleocapsid enters host cell cytoplasm
↓
Uncoating: Release of two copies of ssRNA and viral enzymes
↓
Reverse Transcription: Viral reverse transcriptase converts ssRNA to ssDNA
↓
Formation of Pre-integration Complex:
Linear dsDNA
Gag matrix protein
Accessory vpr protein
Viral integrase
↓
Transport to Nucleus
↓
Integration: Viral dsDNA integrates into host cell chromosome
↓
Integrated State: HIV establishes a latent infection
↓
Latent Replication: HIV can replicate in a latent state
↓
Infect Adjacent Cells: HIV can infect neighboring cells
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(C) Clinical features
Stages of HIV are

Asymptomatic infection with persistent generalised lymphadenopathy
Stage 2 with weight loss recurrent URTI etc.
Stage 3 includes unexplained wt loss, diarrhea, fever, tuberculosis etc.
Stage 4 includes HIV wasting syndrome along with
Antibody detection
Screening assays- Using 3rd or 4th generation ELISA for antibodies against gp120,
p24, gp41
Rapid diagnostic kits-Using Dot blot like Tri-dot, Coombs test etc.
Supplement test- Done to confirm the findings of screening assays
Western blot-antibodies against different gene products are tested and according

to WHO presence of at least 2 envelopes with or without gag or pol is considered
positive.
p24 Antigen detection-Done using 4th generation ELISA but is less sensitive than
antibody assay.
Viral RNA detection- gold standard method for diagnosis
RT-PCR

Branched DNA assay

NAAT- nucleic acid amplification technique

DNA PCR- used for diagnosis in vertical transmission
Isolation of Virus- The virus is isolated in mononuclear cells.
Non-specific test- CD4+ Tcell counts
(D)
Strategy 1 for transfusion/transplant safety check
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Strategy 2A to estimate prevalence
Strategy 2B for diagnosis of symptomatic patients
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CVS
Strategy 3 for diagnosis of asymptomatic patient, antenatal screening. (3 test

kits required).
pportunistic Infection
O
Bacterial opportunistic infections Viral opportunistic infections:
Extrapulmonary tuberculosis Chronic HSV infection
Recurrent septicemia Progressive multifocal

leukoencephalopathy
CMV retinitis
Fungal opportunistic infections: Parasitic opportunistic infections:

Pneumocystis jirovecii pneumonia (PCP) Toxoplasma encephalitis
Esophageal candidiasis Atypical disseminated leishmaniasis
Cryptococcal meningitis
Neoplasia
Kaposi’s sarcoma

Invasive cervical cancer

Non-Hodgkin lymphoma


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30. A 35-year-old male presented with High fever, chills, and fatigue for the past
week. On examination Patient appears pale and fatigued, Temperature: 102.5°F
(39.2°C) Enlarged spleen. The doctor made a clinical diagnosis of malaria.
(A) Explain the life cycle of malaria.
(B) What are the Pathogenesis and clinical features of malaria?
(C) What is the laboratory diagnosis of malaria? (10 Marks)
Answer:
(A) Malaria is caused by the protozoan Plasmodium.

4 major species are responsible for malaria
P.vivax

P.falciparum

P.malariae

P.ovale

It completes its life cycle in 2 hosts i.e. female anopheles mosquito and human. In
humans, the asexual cycle occurs in three stages
pre-erythrocytic schizogony

erythrocytic schizogony

gametogenesis.

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Stage Description
Motile sporozoites exit the circulation and enter the liver
within 30 minutes.
Attachment: Circumsporozoite proteins bind to
hepatocytes’ surface, facilitating sporozoite invasion.
Trophozoite formation inside hepatocytes.
Pre-erythroid Stage
Schizogony: Trophozoite undergoes several fission stages
and transforms into a pre-erythrocytic schizont.
Release of merozoites from hepatocytes into the
bloodstream to infect RBCs.
No major liver injury occurs during this stage.
Merozoites bind to glycophorin receptors on erythrocyte
surfaces and enter via endocytosis.
Trophozoites: Merozoites transform into early and late
trophozoites.
Malaria pigment (hemozoin pigment) forms as a result of
Erythrocytic Stage
hemoglobin digestion.
Schizogony: Late trophozoites undergo schizogony,
producing multiple daughter merozoites.
Gametogony: Some merozoites transform into gametocytes
for mosquito transmission.
(B) Etiology and Clinical Features of Benign Malaria

Triad of Symptoms: Benign malaria is often identified by a triad of clinical
symptoms, which include:
Febrile Attacks

Anemia

Splenomegaly (enlarged spleen)

Fever Paroxysms: Fever in benign malaria occurs in paroxysms, or recurrent

episodes, with the frequency varying depending on the malaria parasite type.
The pattern of paroxysms is as follows:

P. malariae: Occurs every 4 days
Other Plasmodium species: Occurs every 3 days
Three Stages of Fever Paroxysms:

Cold Phase: Lasts from 15 minutes to 1 hour. Patients experience symptoms such
as fatigue, headache, nausea, severe cold, chills, and stiffness.
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High-Temperature Period: The patient develops a high fever, typically ranging

from 39°C to 41°C, with dry and burning skin.
Sweating Stage: Fever decreases during this stage, accompanied by profuse
sweating.
Anemia: Patients with benign malaria develop anemia due to the destruction of
red blood cells (RBCs) by the malaria parasites.
Splenomegaly (Enlarged Spleen): Splenomegaly is caused by the massive proliferation
of macrophages that engulf both parasitized and unparasitized RBCs. The spleen
enlarges due to its role in clearing damaged RBCs.
Pathogenesis of Falciparum Malaria (Malignant Tertian Malaria)
Sequestration: P. falciparum parasites have the unique ability to sequester themselves
within the blood vessels of deep internal organs, consequences:
Parasite sequestration can cause blockage and congestion of blood vessels within
these organs.
The blockage of blood vessels results in reduced oxygen supply (hypoxia) to internal
organs.
Mediation of Sequestration:
Cell Adhesion: Infected red blood cells (iRBCs) adhere to the endothelial cells

by a specific antigen called Plasmodium falciparum erythrocyte membrane
protein-1 (PfEMP-1)
Rosetting: PfEMP-1 also plays a role in binding infected RBCs to uninfected

RBCs, a phenomenon known as rosetting.
Spleen Avoidance: By sequestering themselves within deep blood vessels, the

parasites can avoid passing through the spleen as frequently, thus reducing their
chances of removal by the spleen.
Complications
Cerebral anoxia Hypoglycaemia
Pernicious malaria Renal failure
Black water fever- occurs after DIC

quinine therapy
Severe jaundice
Algid malaria- State of shock.
Tropical splenomegaly syndrome
Non-cardiogenic pulmonary edema
Burkitt lymphoma.
(C) Laboratory diagnosis

Peripheral Blood Smear (PBS):
Gold standard confirmatory test.

Draw blood after the peak of fever and before antimalarial drugs.

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CVS
Two types of PBS:
Thin smears: Speciation of Plasmodium.

Thick smears: Diagnosis, parasite quantification, and pigment demonstration.

Fluorescence Microscopy:
Utilizes acridine orange staining and the Kawamoto technique.

Quantitative Buffy Coat Examination (QBC): Centrifugation of the sample,

followed by smearing and staining with acridine orange.
Antigen Detection with Rapid Diagnostic Tests (RDTs):
Detects various malaria antigens, including:

pLDH (all Plasmodium species), Pf-LDH (P. falciparum).

Parasitic aldolase (all species).

HRP-II (P. falciparum).

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Antibodies Detection:
Limited usefulness as antibodies persist post-cure.

Culture Techniques:
Primarily for malaria antigen production.

RPMI 1640 medium is commonly used for culturing malaria parasites.

Molecular Methods:
Detects 18S rRNA by PCR.


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CVS
31. A 45-year-old female resident of Kolkata presents with prolonged fever, weakness,
and weight loss over the past several months. The patient appears emaciated
and fatigued, with temp-normal hepatosplenomegaly and Pancytopenia with
Elevated liver enzyme levels.
(A) What is the diagnosis?
(B) Explain the life cycle of the causative organism
(C) What is the pathogenesis and clinical feature of the disease?
(D) Write its laboratory diagnosis. (5 Marks)
Answer:
(A) The probable diagnosis is visceral leishmaniasis caused by a hemoflagellate
Leishmania donovani(most commonly).
(B)
(C)
Pathogenesis
Various factors contribute to the development of Visceral Leishmania(VL).

Phagocytosis of promastigotes is facilitated by the binding of surface antigens such
as 63 kDa glycoprotein (gp-63) and lipophosphoglycan (LPG) to specific receptors
on macrophages.
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LPG is the most important virulence factor This prevents phagosome maturation
and protects the parasite from hydrolytic enzymes secreted by phagolysosomes.
GPI is an important surface protein of amastigotes that contributes to protection
against phagolysosomal attack within macrophages.
Clinical Features
Visceral Leishmania also called kala-azar has an incubation period of 2 to 6
months.
Visceral Leishmania is characterized by five symptoms:
Fever- The most common symptom of VL. Onset is sudden, moderate to severe,

and accompanied by chills and chills.
Progressive weight loss

hepatosplenomegaly,

pancytopenia

hypergammaglobulinemia

Lymphadenopathy: Femoral and inguinal nodes are affected commonly
Hyperpigmentation is observed on the face, hands, feet, and abdomen; hence the
name kala-azar or black fever.
Pedal edema and ascites: Occur due to hypoalbuminemia,
Leishmanoma: Nodular skin lesions
Postkala-azar dermal leishmaniasis (PKDL)

PKDL is a non-ulcerative skin lesion that occurs in patients after antimony
treatment. Exposure to sunlight makes it worse.
It begins as a hypopigmented macule eventually forming leprosy-like nodules.
Microscopic detection of amastigotes
Seen as Leishman-Donovan bodies or LD bodies within macrophages
Smears should be stained with Leishman, Giemsa, or Wright stains.
Various samples include

Spleen aspiration
Bone marrow aspirate
Lymph node aspiration
Liver biopsy
Peripheral blood
Biopsy samples of various organs: oropharynx, stomach, etc.
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CVS
Culture
NNN medium: Novy-MacNeal-Nicolle(NNN) medium is the medium of choice
Schneider's Drosophila Insect Medium.
Detection of Antibodies in Serum

False-positive results can occur in patients with leprosy, Chagas disease, and
Cutaneous leishmania due to antibody cross-reactivity.
Direct agglutination test (DAT)
ICT
ELISA
Antigen detection
Done by latex agglutination test
Molecular methods
PCR to detect protozoan DNA.

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32. Write short notes on a) Candida albicans and b) Enteric fever. (10 Marks)
Answer:
(A)
Candida
Common fungal disease in humans
Affects skin, mucous membranes, and internal organs
Candidiasis
Caused by Candida fungus-producing pseudohyphae
Predisposing Factors:
Extremes of age, pregnancy, low immunity, broad-
spectrum antibiotics use, diabetes mellitus, etc.
Virulence Factors:
Pathogenesis
Adhesins for adhesion
Enzymes for tissue invasion
Toxins (pyrogenic glycoprotein extracts)
Pseudohyphae for active infection and invasion
Invasive candidiasis: Hematogenous or local spread
Forms: urinary tract infection, pulmonary candidiasis,
septicemia, meningitis, osteomyelitis, etc.
Clinical Manifestations Mucosal candidiasis: Oral thrush, vulvovaginitis, etc.
Cutaneous candidiasis: Intertrigo (pustules on skin
folds), nail infections, etc.
Allergic candidiasis
Sample Collection depending on the site of infection
(urine, blood, etc.)
Direct microscopic observation showing gram-positive
pseudohyphae
Culture on SDA with antibiotic supplements at 37°C
Blood culture bottles
Colonies appear creamy white, smooth, and pasty
Laboratory Diagnosis after 1 to 2 days
Species Identification Tests
Germ tube test (specific to C. albicans
Dalmau plate culture for clues to species identification
Chrom agar for different species’ color colonies
Carbohydrate assimilation test
Molecular methods like PCR for species-specific
primers
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CVS
Antibody detection using ELISA for cell wall Mannan

antigen
Immunodiagnosis Antigen detection via ELISA for cell wall Mannan
Beta-D glucagon assay for invasive fungal infections,

including invasive candidiasis
(B) There are 3 classifications of salmonella

Clinical- which divides into typhoidal and non-typhoidal
Kauffman-white - this divides on the basis of O(somatic) and H (flagellar) antigens.
Molecular- which further divides on the basis of serotypes
Enteric fever is caused by typhoidal salmonella which includes S.Typhyi and

S.Paratyphi A, B, C.
Pathogenesis
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Typhoid
Stepladder pattern of fever
Headache, chills, body pain
Clinical Features Rose spots (salmon-colored macular-papular rash on the
trunk)
Abdominal pain with nausea and vomiting
Muttering delirium (characterized by meningitis, ataxia,
Complications psychosis)
Bleeding and hemorrhage
Hepatosplenomegaly
Clinical Signs
Relative bradycardia
First week of onset: Blood culture, bone marrow aspiration

Specimen Collection
Second week: Serum for antibodies
and Culture
Third week: Urine and stool culture
Motile gram-negative bacilli
Catalase positive, oxidase negative

Identification
Negative results for indole, citrate, and urease tests
TSI K/A with gas and H2S production

Quantitatively detects antibodies against O and H antigens
Widal Test O agglutination: Chalky clumps of blue color
H agglutination: Loose, fluffy, pink clumps

Antigen Detection ELISA
Molecular Methods PCR to detect Iro B gene and bacterial genetic material
Edition, No. 377
Edition, No. 303

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CVS
33. A 25-year-old man resident of Bihar presents to the opd with massive enlargement
of left leg and scrotum. On examination, the doctor notices non-putting type
edema in the left limb and makes a diagnosis of filariasis. Further investigation
revealed it is due to wuchereria bancrofti.
(A) What is the life cycle of this organism
(B) What are the Pathogenesis and clinical features?
(C) Write the laboratory diagnosis. (10 Marks)
Answer:
Filariasis is a vector-borne disease caused by nematodes
Lymphatic filariasis- caused by Wuchereria bancrofti, Brugia malayi and Brugia
timori.
Cutaneous and ocular filariasis- caused by Loa loa, Onchocerca and Mansonella.
The life cycle of wuchereria bancrofti. It completes its life cycle in 2 host
Man is the definitive host

Culex is the intermediate host and vector for the disease.

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(B)
Pathogenesis
Tissue changes result from the body's response to:
Live adult worms in lymphatic vessels
Toxins produced by these worms
Secondary bacterial and fungal infections
Severe inflammation of the lymphatic system occurs, leading to fibrosis and lymph
flow blockage, causing widespread edema in the affected region.
Endosymbiosis with Wolbachia and Wuchereria infections occurring together.
Clinical Features
Incubation period: 8 to 16 months.
Lymphatic Filariasis (4 Forms):
Endemic (asymptomatic, seen in endemic zones)
Asymptomatic microfilariae (present in blood, no clinical signs)
Acute filariasis:
High-grade fever

Lymphangitis

Tender lymph node enlargement

Epididymitis (in males)

Local edema

Chronic filariasis (10 to 15 years after acute infection):
Severe lymphatic obstruction

Hydrocele

Elephantiasis

Funiculitis and epididymitis

Tropical Pulmonary Eosinophilia
Immune Complex-Mediated Manifestations:
Nephrotic syndrome

Arthritis

Microscopic Examination:
Microfilariae in blood (collected according to their movement time)

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CVS
DEC Provocation Tests: Provokes microfilariae to enter the blood for detection.
QBC (Quantitative Buffy Coat Examination): Uses fluorescent staining for increased
sensitivity.
Head end Tail end Species

The cephalic space ratio is 1:1 No nuclei in the tip Wuchereria bancrofti
The cephalic space ratio is 2:1 Nuclei extend till tail tip Brugia malayi
Leishman and Giemsa Stains for microfilariae detection in peripheral blood smears.
Antigen Detection
ADq2 and Og4C3 antigens detected using ELISA and ICT.
Antibody Detection
Flow-through assays to detect parasite-specific IgG4 antibodies.
Imaging Methods:
USG (Ultrasonography): Reveals dilated tortuous lymphatics with moving worms
(filariasis dance sign).
Lymphoscintigraphy.
X-ray: Detects calcified dead worms.
Molecular Methods:
Real-time PCR for detection.
Other Tests
Eosinophilia.
Elevated IgE.
Biopsy of lymph nodes.
Edition, No. 370
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GIT
34. Enumerate common causes of food poisoning. (3 Marks)
Answer:
Food poisoning is an illness caused by the consumption of food or beverages
contaminated with microorganisms or toxins.
Timing of
Clinical Likely 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 Enterohemorrhagic 6–72 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 2–5 days Clinical presentation, Undercooked
diarrhea jejuni post-ingestion stool culture, PCR poultry, dairy
Flaccid Clostridium 12–72 h Clinical presentation, Improperly

paralysis, botulinum post-ingestion electromyography, canned foods
diplopia,
toxin assay
dysphagia
Fever, myalgia Listeria Variable Clinical presentation, Soft cheeses,
(pregnant) monocytogenes blood culture, PCR deli meats
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GIT
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

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35. Write a short a note on giardiasis (5 Marks)
Answer:
Morphology
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)
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 discs (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.
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GIT
Clinical features
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
Acute giardiasis: Symptoms include diarrhea, bloating, abdominal pain etc.
Steatorrhea: This occurs due to fat malabsorption. There is malodorous pale sticky
stools are released in feces.
Chronic giardiasis: This is due to persistence of infection and include foul smelling
diarrhoea flats along with extra intestinal manifestations like urticaria anterior
uveitis and generalised weight loss.
Stool Examination:
A fresh stool sample is collected from the patient.
Wet mount: The sample is microscopically examined for the presence of Giardia
cysts or trophozoites.
Concentration techniques, such as sedimentation or flotation, may be used to
increase the chances of detecting the parasites
ASHISH89 SEHRA
Stool Antigen Test known as coproantigen

Enzyme immunoassays (EIAs) or immunochromatographic assays are used in this
method.
They detect specific Giardia antigens in the stool.
Molecular Tests
Polymerase chain reaction (PCR) tests are highly sensitive and specific for Giardia
diagnosis.
Serological Tests
Using ELISA and IFA
Culture
In Diamond medium . These are done for research generally.
Duodenal Aspirate or Biopsy: Done using Entero-string test
In severe or chronic cases of giardiasis, or when other diagnostic methods are
inconclusive, an endoscopy procedure may be performed.
A sample is collected directly from the duodenum, which is the part of the small
intestine most commonly affected by Giardia.
Edition, No. 433

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GIT
36. Write in detail about the diarrhoea causing E.coli? (10 Marks)
Answer:
Virulence Factors
Fall into two categories: surface antigens and toxins.
Surface antigens encompass somatic (O), flagellar (H), capsular (K), and fimbrial
antigens.
Somatic 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.

Toxins:
Enterotoxins (heat-labile or heat-stable).

CNF1 is cytotoxic to bladder and kidney cells, contributing to urinary tract

infections.
Clinical Features
E. coli causes diverse manifestations:
Urinary tract infection (UTI) 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 (neonatal).

Wound and soft tissue infections (e.g., cellulitis).

Bacterial prostatitis.

Osteomyelitis.

Direct Smear (Gram Staining): Gram-negative straight rods.
Culture: Aerobic and facultative anaerobe, using media like blood agar and
MacConkey agar.
Identification: MALDI-TOF or VITEK, Catalase test (positive), Oxidase test (negative),
ICUT tests (Indole test, Citrate test, Urease test, TSI test).
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Diarrheagenic E.coli
Diarrheagenic E. coli strains are distinct from the commensal E. coli that normally
inhabit the intestine. There are six pathotypes of diarrheagenic E. coli:
Major Clinical
Pathotype Characteristics
Presentation
Common in infantile diarrhea Watery diarrhea,
outbreaks. especially in infants
Adhesion to intestinal mucosa, and children.
Enteropathogenic
causing A/E lesions (attaching and
E. coli (EPEC)
effacing lesions)
Disrupts the brush border
epithelium.
Major cause of traveler’s diarrhea. Acute watery
Produces heat-labile and heat- diarrhea in both
Enterotoxigenic
stable toxins. infants and adults.
E. coli (ETEC)
Adheres to intestinal mucosa via
colonization factor antigen (CFA).
Biochemically, genetically, and Dysentery (bloody
pathogenically related to Shigella. diarrhea with
Enteroinvasive
Invasive, not toxigenic. mucus and
E. coli (EIEC)
Invades epithelial cells through blood), resembling
virulence marker antigen (VMA). shigellosis.
Serotype O157:H7 is common, Hemorrhagic
but others can cause infections. colitis (gross
Typically transmitted through bloody diarrhea),
Enterohemorrhagic
contaminated food. abdominal pain,
E. coli (EHEC)
Produces verocytotoxin or Shiga fecal leukocytosis.
toxin (Stx1 and Stx2). Hemolytic Uremic
Syndrome (HUS)
Adheres to HEp-2 cells in a Persistent and
stacked-brick fashion. acute diarrhea,
Enteroaggregative
Produces EAST 1 toxin traveler’s diarrhea,
E. coli (EAEC)
(enteroaggregative heat-stable and persistent
enterotoxin 1). diarrhea in infants.
Adheres to HEp-2 cells in a diffuse Diarrheal disease,
Diffusely-Adherent pattern. mainly in children.
E. coli (DAEC) Expresses diffuse adherence
fimbriae.
Edition, No. 401
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GIT
37. Write a short note on H.pylori infection. (5 Marks)
Answer:
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:
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.
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.
Adhesins: can bind to mucosal epithelium using adhesion molecules like blood group
antigen-binding adhesin and adherence-associated lipoprotein.
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:
Vacuolating Cytotoxin (VacA): This toxin is secreted by H. pylori and causes the
formation of vacuoles within the cytoplasm of epithelial cells.
Cytotoxin-Associated Gene A (CagA): CagA helps the bacterium alter the host cell's
metabolism.
Molecular Mimicry
Immune Tolerance: H. pylori may downregulate T cells, promoting immune

tolerance.
Autoantibodies: Autoantibodies generated due to molecular mimicry can cross-
react with mucosal epitopes, contributing to chronic active gastritis.
Acute Gastritis: Typically affects the antrum of the stomach
Pangastritis: Increases the risk of gastric adenocarcinoma.
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.
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.
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Chronic Conditions Associated with H. pylori Infection

Chronic Atrophic Gastritis
Autoimmune Gastritis
Pernicious Anemia
Adenocarcinoma of the Stomach
Gastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphomas
Invasive Tests:
Endoscopy-Guided Biopsies: During endoscopy, multiple biopsies are taken from
the gastric mucosa, including the antrum and corpus.
Histopathology with Warthin Starry Staining: Biopsy samples can be stained and
examined for the presence of H. pylori.
Microbiological Methods
Gram Staining: H. pylori appears as curved gram-negative bacilli with a distinctive
seagull-shaped morphology.
Culture: Culture is highly specific but not very sensitive. Skirrow’s media and
chocolate agar are commonly used culture media.
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: In this noninvasive test in which we detect labeled Carbon in
breath of the patient
Fecal antigen detection: highly sensitive and specific test
Antibody detection: Done using ELISA
Treatment
Triple therapy is commonly used which consists of one PPI + metronidazole +
tetracycline.
Edition, No. 420

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GIT
38. Write a short note on Clostridium difficile. (5 Marks)
Answer:
C. difficile
Obligate anaerobic, gram-positive, spore-forming bacillus
Causes pseudomembranous colitis
Introduction
Linked to prolonged antimicrobial drug use(Ceftriaxone,
Clindamycin, Ciprofloxacin etc.)
Healthcare-Associated Infection
Risk Factors:
Prolonged Hospital Stay
Pathogenesis Prolonged Antimicrobial Use
Toxin Production (Toxins A and B disrupt cellular actin
cytoskeleton)
Infants are less susceptible due to lacking toxin receptors
Diarrhea (most common)
Fever
Abdominal Pain
Clinical
Leukocytosis
Manifestations
Blood in Stool
Pseudomembrane Formation (whitish-yellow plaques on
colonic mucosa)
Stool Culture (under anaerobic conditions with selective
media)
Toxin Demonstration (via assays, antigen detection, toxin
A/B presence)
Glutamate Dehydrogenase (GDH) detection (not specific
Laboratory for toxins)
Diagnosis
Molecular Methods (PCR, real-time PCR, gene Xpert for
specific genes)
Colonoscopy (if pseudomembranes observed)
Histopathology (using hematoxylin and eosin stain on

pseudomembranes)
Treatment DOC: Oral vancomycin (Fidaxomicin/Metronidazole)
Edition, No. 422

ASHISH95 SEHRA
39. A 5-month-old child presents to the emergency in a state of shock. Mother

complains that he had 10 episodes of loose stools in the past 6 hours. The child
is lethargic, not feeding and has cold hands. Temperature is 100 F
He is not vaccinated.
(A) What is the probable diagnosis and enumerate the infectious causes of pediatric
diarrhoea?
(B) Write the Pathogenesis and clinical features of the disease.
(C) Write it’s laboratory diagnosis. (10 Marks)
Answer:
(A)
The probable diagnosis is viral gastroenteritis most commonly caused by Rotavirus

Other causes of pediatric diarrhoea are-
Norovirus
Sapovirus
Adenovirus
Astrovirus.
(B) Morphology of the Virus

Icosahedral symmetry
Possesses a triple-layered, wheel-shaped capsid
Segmented double-stranded RNA genome
11 segmented genome
6 structural proteins (VP1 to VP7) excluding VP5, and 6 non-structural proteins
Pathogenesis
Transmission: through contaminated food, water, or contact with infected
individuals.
Targeting Enterocytes: infect and destroy enterocytes in the small intestine.
Multiplication: replicate and multiply in the cytoplasm of enterocytes.
Damage to Transport Mechanisms: disrupts normal cell functioning, leading to

secretory diarrhea.
NSP4 Enterotoxin: alters intestinal cell function, causing secretory diarrhea.
Incubation period: approximately 1 to 3 days.
ASHISH96 SEHRA
GIT
Symptoms: abrupt onset, including vomiting, watery diarrhea, fever, abdominal

pain, electrolyte imbalance, and possible shock.
(C) Laboratory Diagnosis:

Direct Detection of the Virus:
Ideal specimen: early-collected feces.
Methods: Immunoelectron Microscopy (IEM), isolation, detection of viral antigen

(ELISA, latex agglutination), RT-PCR.
Serologic Tests:
ELISA for changes in antibody titers.
Treatment of Viral Gastroenteritis:

Supportive care focuses on fluid and electrolyte correction through oral or
parenteral fluid replacement.
Vaccines
Rotavac:
Contains live attenuated Rotavirus, and provides cross-protection against various
types.
Schedule: Administered orally in three doses at 6, 10, and 14 weeks of age,
alongside routine vaccines.
Common side effects: crying, irritability, fever, and diarrhea.
Rotarix:
Live attenuated vaccine, requires reconstitution before use.
Given in 2 doses at 6 and 10 weeks of age.
Other Agents:
Virus Characteristics
Transmitted by fecal-oral route
Rotavirus Affects the small intestine
Causes secretory diarrhea
Part of Caliciviridae family
Icosahedral shape
Norovirus
Approximately 27-40 nm in size
Causes epidemic gastroenteritis
Part of Caliciviridae family
Sapovirus Icosahedral shape
Approximately 27-40 nm in size
ASHISH97 SEHRA
Types 40 and 41 cause diarrhea

Adenovirus Common in young children
Responsible for diarrhea
STAR-like morphology
Astroviruses Approximately 28-30 nm in size
Edition, No. 424

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GIT
40. Write a short note on Ascaris. (5 Marks)
Answer:
Introduction: Ascaris lumbricoides, a common intestinal parasite(roundworm),
inflicts significant morbidity worldwide.
Incubation Period: The incubation period for Ascaris infection typically spans
60-70 days.
Life cycle-
Clinical Presentation
Pulmonary Phase:
During this initial phase, migrating larvae invade the lungs, inciting an immune-
mediated hypersensitivity response. Symptoms commonly emerge in the second
week and include:
Non-productive cough

Chest discomfort

Fever

ASHISH99 SEHRA
In severe cases, pulmonary manifestations may escalate to eosinophilic pneumonia,

known as Loeffler's syndrome. This condition may manifest with:
Dyspnea

Transient patchy infiltrates visible on chest X-rays

Peripheral eosinophilia

Intestinal Phase
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 nutrient
competition with the parasites.
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

Extraintestinal Complications: Larger worms may enter and obstruct the biliary
tree, giving rise to:
Biliary colic

Cholecystitis

Pancreatitis

Allergic Manifestations: The presence of adult worms can provoke allergic reactions,
leading to symptoms like:
Fever
Urticaria
Angioneurotic edema
Conjunctivitis
Laboratory Diagnosis:
Stool Examination: Both fertilized and unfertilized Ascaris eggs can be identified
in stool samples using saline and iodine wet mounts.
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.
Detection of Larvae: During the early pulmonary migratory phase, larvae can be
found in sputum or gastric aspirates before eggs appear in stool samples.
ASHISH100SEHRA
GIT
Antibodies Detection: Although not commonly performed, serological tests, such

as ELISA, can be used to detect antibodies against Ascaris.
Molecular Methods: PCR targeting the cytochrome oxidase-1 gene of Ascaris eggs
in stool samples can provide a sensitive diagnostic tool.
Other Tests: Eosinophilia and the presence of Charcot Leyden crystals in sputum
can provide additional diagnostic clues.
Treatment
Albendazole
Edition, No. 461

ASHISH
101 SEHRA
41. Write in detail about Entamoeba histolytica including intestinal amoebiasis and
amoebic liver abscess. (10 Marks)
Answer:
Morphology
E. histolytica exists in three stages:
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.
Precyst: An intermediate stage between trophozoite and cyst.
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.
Life Cycle of Entamoeba histolytica

It completes its life cycle within a single host, which is typically a human.
Infective Form: The mature quadrinucleate cyst
Mode of Transmission:
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: In very rare cases, vectors such as flies and cockroaches

Development in the Human

Small Intestine: 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.
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

Amoebic Dysentery

Invasive Amoebiasis

Encystation: When intestinal lesions start to heal, and the patient improves,

trophozoites transform into precysts and then into cysts, which are subsequently
liberated in feces.
Virulence factors
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.
ASHISH102SEHRA
GIT
Other Virulence Factors: These include
Amoebapore, which forms pores on the target cell membrane, causing ion

leakage.
Hydrolytic enzymes

Pathogenesis
Colonization: Trophozoites initially colonize the intestinal mucosa, and this process
is facilitated by the presence of bacterial flora that lower the oxygen tension.
Adhesion: using Gal/GalNAc lectin molecules.
Flask-shaped Ulcers: Trophozoites produce characteristic flask-shaped ulcerative

lesions in the large intestine, with a broad base and a narrow neck.
Invasion: Following ulcer formation, amoebae invade the large intestinal wall and
can migrate to extraintestinal sites.
Clinical Manifestations of Intestinal Amoebiasis:
Incubation Period: Typically varies from one to four weeks.
Asymptomatic Cyst Passers: About 90%
Symptomatic Cases:
Amoebic Dysentery: Symptoms include bloody diarrhea (up to 10 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:
Intestinal Perforation and Amoebic Peritonitis
Toxic Megacolon and Intussusception
Amoebiasis Cutis or Cutaneous Amoebiasis: Presents as perianal skin ulcers,
Ameboma (Amoebic Granuloma): A diffuse pseudotumor-like mass of granulomatous
tissue found in the rectosigmoid region.
Chronic Amoebiasis: Characterized by thickening, fibrosis, stricture formation, and
scarring.
Clinical manifestations of Amoebic liver abscess

Tender Hepatomegaly: Enlargement of the liver with tenderness is a common and
consistent feature.
Fever, weight Loss, profuse sweating
Anchovy sauce pus
ASHISH
103 SEHRA
Complications of Amoebic Liver Abscess include:

Rupture: The abscess may rupture in various directions within the liver, leading to
the discharge of its contents into neighboring organs (lungs for example)
Subphrenic Abscess: Rupture below the diaphragm can result in a subphrenic
abscess and generalized peritonitis.
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.
Microscopy: Examination of liver pus or stool under a microscope can detect
trophozoites, the active form of the amoeba.
Stool culture
Polyxenic culture in National Institute of Health media (NIH).

Axenic culture using Diamonds media.

Sigmoidoscopy done to take biopsies and stained with PAS stain and H&E stain
to detect trophozoite.
Antigen Detection: Using ELISA The lectin antigen can be demonstrated in
stool,serum, liver pus, and saliva.
Antibody Detection: Serum antibody detection is more useful for extraintestinal
amoebiasis than intestinal amoebiasis. ELISA tests are available
Molecular Diagnosis: PCR and real-time PCR
Imaging Methods: Ultrasonography (USG) of the liver can reveal the location of the
abscess and its extension. CT scans and MRI scans are alternative options.
Edition, No. 427

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GIT
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 described as
"rice water" in appearance. He says that he went to eat some street food 2 days
back.
(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-
Non-halophilic- They can grow without salt but their growth is enhanced if 1%
salt is present in the medium. Eg- v.cholerae and v.mimicus
Halophilic- These require a specific concentration of salt in the medium for their
optimal growth.eg-v.vulnificus,v. parahaemolyticus etc.
(B) Pathogenesis
Mode of Transmission: through the ingestion of contaminated water or food. The
infective dose is high,
Reduced Gastric Acidity: Conditions that reduce gastric acidity, such as
hypochlorhydria or the use of antacids, can promote the transmission of Vibrio
cholerae.
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.
Adhesion and Colonization: The bacterium adheres to the intestinal epithelium,
facilitated by toxin-coregulated pilus (TCP).
Cholera Toxin: Once established in the small intestine, Vibrio cholerae produces
cholera toxin, a potent enterotoxin.
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Clinical features
Cholera caused by V. cholerae O1 or O139 can manifest in various ways,
Asymptomatic Infection: Many infected individuals do not show any symptoms

and remain asymptomatic.
Mild Diarrhea or Cholera: Some individuals may experience mild diarrhea.
Cholera Gravis (5% of Cases): This is the most severe form and is characterized by
explosive, life-threatening diarrhea.
Common Clinical Manifestations:
Watery Diarrhea: Cholera typically starts suddenly with painless, profuse, watery
diarrhea that can quickly become voluminous.
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.
Vomiting
Muscle Cramps: Electrolyte imbalances due to fluid loss can lead to muscle cramps.
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GIT
Specimens collection
Freshly collected watery stool is the preferred specimen for acute cases of cholera.
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:
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.
Motility testing using the hanging drop method can show active, darting motility
of the bacteria.
Culture:
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
Alkaline peptone water

Monsur’s taurocholate tellurite peptone water

Selective media
TCBS agar- Thiosulphate citrate bile sat agar produces yellow colonies

Alkaline bile salt agar- produces oil drip colonies

MacConkey agar

Identification:
Catalase and oxidase: Positive.

ICUT test: This test assesses reactions to various biochemicals, including:

Indole test: Positive.

Citrate test: Variable.

Urease test: 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.
Hemodigestion: On blood agar, V. cholerae causes nonspecific lysis of blood cells,
seen as a greenish clearing.
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String test: On mixing the colony with 0.5% deoxycholate, the colony becomes
mucoid and forms a string when lifted with a loop.
Antigen detection
Dipstick tests are available for cholera.
Molecular methods
PCR can be used to detect cholera-specific genes in stool samples.
(C)
Halophilic vibrio can withstand salt concentration even more than 6% while non-
halophilic can only withstand up to 6%.
Vibrio parahaemolyticus Infections:
These infections are commonly associated with consuming raw or uncooked seafood,
particularly oysters.
Clinical manifestations include food-borne gastroenteritis, which typically presents
as watery diarrhea or, rarely, as dysentery with abdominal cramps.
Morphology-Bipolar staining in fresh specimens
TCBS agar-green colonies on
Kanagawa phenomenon: Beta hemolysis on wagatsuma agar.
Swarming on blood agar.
Vibrio vulnificus Infections:

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.
Laboratory diagnosis involves culturing the bacteria from blood or cutaneous
lesions.
V. vulnificus ferments lactose, which helps differentiate it from other Vibrio

species.
Edition, No. 411
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Hepatobiliary
43. Write the difference between Hepatitis A, C and E. (5 Marks)
Answer:
Hepatitis A Virus Hepatitis C Virus Hepatitis E Virus

Aspect
(HAV) (HCV) (HEV)
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
usually self-limiting chronic infection. self-limiting
Infection
Yes No In some regions,

Vaccination
vaccines are available
Available
Generally milder, Can lead to Severity varies, often

rarely fatal chronic liver mild but can be
Severity of
disease, cirrhosis, severe in some cases
Illness
and hepatocellular
carcinoma
2-6 weeks 2-12 weeks 2-9 weeks
Incubation
Period
Serology tests (IgM Blood tests Serology tests (IgM

Diagnosis and IgG) and liver for HCV RNA, and IgG) and liver
function tests antibodies function tests
Supportive care, Antiviral Supportive care,
no specific antiviral medications no specific antiviral
Treatment
treatment (Direct-acting treatment
antivirals)
Anyone can be People who share Pregnant women
infected needles, healthcare and those with
Risk Groups
workers at risk compromised
immune system.
Edition, No. 476
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44. Write a short note on Hydatid disease. (5 Marks)
Answer:
Causative Agent:
Cystic Echinococcosis (Hydatid Disease) caused by Echinococcus granulosus.
Other Echinococcus Diseases:
Alveolar Echinococcosis (caused by E. multilocularis).
Polycystic Hydatid Disease.
Unicystic Hydatid Disease.
Morphology:
Adult worm resides in the intestine of definitive hosts (e.g., dogs).
Larval form (hydatid cyst) causes cystic lesions in various organs.
Life Cycle:
Involves definitive hosts (dogs) and intermediate hosts (usually herbivores, sometimes
humans).
Transmission:
Humans are infected by ingesting food contaminated with dog feces containing
E. granulosus eggs.
Pathogenesis and Clinical Features:
Fluid-filled bladder-like cyst.
Cyst wall consists of pericyst, ectocyst, and endocyst.
Brood capsules with protoscolices develop inside the cyst.
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Hepatobiliary
Hydatid fluid within the cyst is antigenic and toxic.

Symptoms vary from asymptomatic to abdominal mass, liver enlargement, biliary
or bronchial obstruction, secondary infections, and anaphylactic reactions.
Can affect various organs, with the liver and lungs being common sites.
Laboratory Diagnosis (WHO Classification):
CE1: Active cyst with visible wall and internal echoes (snowflake sign).
CE2: Active cyst with visible wall and internal septation (honeycomb appearance).
CE3: Transitional with detached laminar membranes or partially collapsed (Water
lily sign).
CE4: Inactive with non-homogeneous mass.
CE5: Inactive cyst with a thick calcified wall.
Hydatid Fluid Microscopy:
Examination for hydatid sand.
Histological Examination:
Stains like Giemsa, H & E, and PAS are used on surgically removed cysts to
demonstrate cyst wall layers and brood capsules.
Antibody Detection:
ELISA using E. granulosus cyst fluid antigen or recombinant B2t antigen.
DIGFA detects serum antibodies against native antigens.
Immunoblot (Western blot) is highly specific for confirmation.
Antigen B is used for seroepidemiological studies.
Imaging Methods:
X-rays detect hepatomegaly and calcified cysts (liver and lungs).
Ultrasound (USG) is preferred for its accuracy.
CT scans provide detailed information, especially for calcified lesions.
MRI can be used.
Molecular Methods:
PCR targeting mitochondrial DNA.
PCR-RFLP (PCR-Restriction Fragment Length Polymorphism).
Skin Test (Casoni Test):
Immediate hypersensitivity reaction (wheal and flare) after injecting hydatid

fluid antigens.
Edition, No. 493
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45. You are an intern working in the department of medicine. While taking the
sample of a patient you accidentally prick yourself with the same 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:
HBV is the most common cause of viral hepatitis. It is the only DNA virus among
other viruses that cause hepatitis.
It belongs to the family Hepadnaviridae.
Hepatitis B (HBV)
(A) Morphological forms of HBV
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.
(B) Viral Antigens

Hepatitis B Surface Antigen (HBsAg): Complex antigen with common and type-
specific epitopes, resulting in subtypes adw, ayw, adr, and ayr.
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Hepatobiliary
Hepatitis B Core Antigen (HBcAg): Intracellular core protein not secreted into the
bloodstream.
Hepatitis B e Antigen (HBeAg): Soluble antigen, indicator of active viral replication.
Viral Genome:
S Gene: Codes for the surface antigen (HBsAg).
C Gene: Comprises pre-C region (precursor of HBeAg) and C region (HBcAg).
X Gene: Codes for HBxAg, which activates transcription of cellular and viral genes,
linked to hepatocellular carcinoma.
P Gene: Codes for polymerase (P) protein with DNA polymerase, RNase H, and
reverse transcriptase activities.
Transmission:
Parenteral Route: Common transmission through blood, needlestick injuries, and
percutaneous exposures.
Medical Procedures: Inoculation during medical procedures without proper infection
control.
Sexual Transmission: Significant in developed countries, especially among homosexual
males.
Vertical Transmission: From infected mothers to babies during pregnancy,
childbirth, or breastfeeding.
Direct Skin Contact: Through contact with infected skin/mucous membranes.
High-Risk Groups: Healthcare workers, paramedical staff, sex workers, recipients

of blood transfusions or organ transplants, drug addicts.
(C) Clinical Features
Incubation Period: 30 to 180 days.
Subclinical Infection: Some show no significant symptoms.
Acute Hepatitis: Manifests with symptoms:
Pre-Icteric Phase: Fatigue, abdominal discomfort, gastrointestinal symptoms.

Icteric Phase (Jaundice): Yellowing of skin and eyes, indicating liver dysfunction.

Hepatic Complications: Cirrhosis, Hepatocellular carcinoma (HCC), fulminant

hepatitis.
Extrahepatic Complication: Serum-sickness syndrome.
(D) Laboratory Diagnosis

Viral Markers:
HBsAg: Appears within 1 to 12 weeks, indicates infectivity.

HBeAg and HBV DNA: Markers of active viral replication.

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Anti-HBc Antibody: IgM indicates acute hepatitis, IgG persists long-term.

Anti-HBs Antibody: Indicates immunity.

Molecular Test: HBV DNA detection using PCR.
Non-Specific Tests: Elevated liver enzymes, elevated serum bilirubin.
(E) Prevention
Active Immunization:
Vaccine Type: Recombinant subunit vaccine using HBsAg.
Route: Intramuscular, typically in the deltoid.
Schedule: Three doses at 0, 1, and 6 months for adults; 6, 10, and 14 weeks for
infants.
Protection Marker: Anti-HBsAg antibody titer of ≥ 10 mIU/mL.
Non/Low Responders: About 5-10% do not require further vaccination.
Passive Immunization:
Hepatitis B Immunoglobulin (HBIG): Provides temporary protection for 3-6
months.
Administration: Intramuscular, ideally within hours but no later than 7 days after
exposure.
Dose: 0.06 mL/kg (or 10-12 IU/kg) as a single dose.
Edition, No. 479
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Skin and Soft tissue
46. Write a short note on cutaneous leishmaniasis (3 Marks)
Answer:
Cutaneous leishmaniasis
Causative Agent Leishmania tropica complex
Vector Sandfly
Habitat (Protozoan) Resides in reticuloendothelial cells

Painless papule
Nodular
Clinical Features
Ulceration
Possible disfigurement/scarring
Cutaneous Leishmaniasis (CL)- Oriental sore
Leishmaniasis Recidivans (LR)- Granulomatous reaction
granulomatous reaction in which new lesions appear years
Types
after the primary wound caused by L.tropica has been
healed
Diffuse Cutaneous Leishmaniasis- extensive skin lesions
Microscopy (Amastigotes)
Diagnosis Culture (NNN medium, Schneider Drosophila medium)
Montenegro Test (for delayed hypersensitivity)
Topical Therapy (e.g., paromomycin, methyl benzethonium
Treatment ointment)
Systemic Therapy (e.g., fluconazole, pentavalent antimony)
Characteristic Chiclero Ulcer (persistent ear ulceration)
Lesions (New Espundia (ulcerative lesions on mucous membranes, may
World Leishmania) lead to cartilage erosion)
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47. What are the various infective conditions of the skin and the organism causing
them? (3 Marks)
Answer:
Superficial
Clinical feature Organisms
epidermis
Ringworm or tinea Because of their ability to utilize Dermatophytes
infection keratin, they infect keratinized
Trichophyton—infects skin,
layers of epidermis, hair and
hair and nail
nails. The skin lesions appear as
annular or ring-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 may S. pyogenes, S. aureus (for
be either non-bullous or bullous bullous impetigo)
that rupture and develop into
honey-coloured crusts
Erysipelas Non-necrotizing inflammation S. 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
lymphadenopathy
Erythrasma Chronic infection of the Corynebacterium
keratinized layer of the minutissimum
epidermis; lesions are dry, scaly,
itchy, and discolored (reddish
brown)
Erysipeloid Purplish-red, non-vesiculated Erysipelothrix
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
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INFECTION OF SKIN APPENDAGES

Infection of the hair follicle
Folliculitis/carbuncle/furuncle- caused by Staph aureus.

Infection of the sweat gland
Hidradenitis- caused by Staph aureus, Streptococcus agalactiae, Bacteroides etc.

Infection of the sebaceous gland
Sebaceous cyst caused by Staph aureus

Infection of nail
Onychomycosis- caused by Tinea unguium and Candida albicans

Green nail- caused by pseudomonas aeruginosa

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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 mucosa Sexual 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
waist
Ocular lesions
Neonatal herpes
Skin lesions— above the
waist
Neurovirulence Less More
Drug resistance Less More
LABORATORY DIAGNOSIS
Cytopathology-
Wright’s or Giemsa stain- reveals inclusion bodies known as Lipschultz body

formation of multinucleated giant cells known as Tzank cells having ground glass

chromatin.
Virus isolation by
McCoy cell line used to demonstrate diffuse rounding and ballooning of cell lines

Shell vial culture—detects antigens in cell line by IF.

Antigen detection- by direct IF
DNA detection by PCR and real-time PCR
Serology By ELISA we detect antibodies against glycoprotein G.
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49. What is the classification of Herpesviruses. Short note on Kaposi Sarcoma.
(3 Marks)

Answer:
DNA VIRUS INCLUDE

Herpesvirus
Smallpox virus
Parvovirus
HPV
Duration of replication
Subfamily Site of latency Common name
and cytopathology
Short (12-18 hours) Neurons Herpes simplex virus type 1
Cytolytic
Herpes simplex virus type 2
Alpha
Varicella-zoster virus (HHV-
3/VZV)
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)

tissues (B cells)
Lymphoproliferative
Gamma
Kaposi’s sarcoma-associated
herpesvirus (HHV-8)
KAPOSI'S SARCOMA (KS)

Cause: Caused by Human Herpesvirus 8 (HHV-8) infection.
Common in: Often associated with HIV/AIDS and more prevalent in specific ethnic
groups.
Appearance: Painless, reddish-purple or brownish skin lesions or nodules; may
affect the mouth and internal organs.
Diagnosis: Confirmed through biopsy of affected tissue.
Treatment: Depends on severity; includes ART for HIV, local therapies, and systemic
treatment.
Prognosis: Varies based on subtype and overall health; manageable with early
detection and treatment.
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50. 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)

This type of larval migration occurs in the skin and subcutaneous tissues.
It is primarily caused by the parasitic worm Ancyclostoma.
VISCERAL LARVAL MIGRATION

In this form, the larva migrates to the intestine, disrupting the normal life cycle.
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.

Stool Microscopy: The presence of Rhabditiform larvae is a diagnostic marker.
Entero-test: Microscopy of duodenal aspirate.
Stool Culture: Using the agar plate technique.
Serology: ELISA is employed to detect antibodies against crude larval antigens.
Coproantigen: ELISA is used to identify larval antigens in stool samples.
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)
Larva currens presents with gastrointestinal and cutaneous symptoms.
Complications can lead to hyperinfection syndrome involving the central nervous
system.
It is characterized by its rapid rate of cutaneous spread.
Molecular Method: Detecting larval DNA in human tissue via PCR.
Eosinophilia: Elevated levels of eosinophils in blood and sputum can be indicative.
To reduce the risk of larval migration infections:
Maintain personal hygiene.
Avoid barefoot walking in risky areas.
Deworm pets regularly.
Cook meat thoroughly, especially pork.
Educate about infection risks and precautions.
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51. Write in brief about chromoblastomycosis. (3 marks)
Answer:
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
Introduction Chronic subcutaneous fungal infection with slow-growing
lesions
Causative Agents Fonsecaea pedrosoi
F. compacta
Phialophora verrucosa
Cladosporium carrionii
Rhinocladiella aquaspersa
Clinical Presentation Various lesion types: verrucose, crusted, ulcerative, nodular,
or tumor-like
Sclerotic Bodies Brown, thick-walled, round cells (5-12 µm) with internal
transverse septa
Diagnostic Feature Presence of sclerotic bodies in histopathological exams
Treatment Surgical removal of lesions followed by itraconazole
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52. Write a short note on anthrax. (5 marks)
Answer:
Causative organism:
Anthrax is caused by Bacillus anthracis.
Virulence Factors and Pathogenesis:

Anthrax Toxin: Anthrax toxin is a tripartite toxin consisting of three fragments:
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.
Protective Factor: This binding fragment attaches to host cell receptors, facilitating
the entry of other toxin fragments into host cells.
Lethal Factor: This fragment induces cell death by cleaving host cell MAPK
(mitogen-activated protein kinases).
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:
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: Inhalation 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
Cutaneous anthrax: Characterized by Malignant pustule
Pulmonary anthrax: Hemorrhagic pneumonia along with hemorrhagic mediastinitis

and meningitis.
Specimen Collection:
Pus, Swab, or Tissue from Malignant Pustule: This is the primary specimen for
cutaneous anthrax.
Sputum: Collected for pulmonary anthrax cases.
Blood: Particularly important in cases of septicemia.
Cerebrospinal Fluid (CSF): If hemorrhagic meningitis is suspected.
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Gastric Aspirate, Feces, or Food: In cases of intestinal anthrax.
Ear Lobes from Dead Animals: Useful in veterinary diagnosis.
Direct Demonstration:
Gram Staining: B. anthracis appears as gram-positive, large rectangular rods.
Spores are usually not seen in clinical samples.
McFadyean’s Reaction: Staining technique to demonstrate the polypeptide capsule
surrounding the bacilli.
Direct Immunofluorescence Test (Direct-IF): Detects capsular and cell wall
polypeptide antigens using fluorescent-tagged monoclonal antibodies.
Culture:
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.
“Medusa head appearance”: When viewed under a microscope, the edge of the

colony looks like locks of matted hair.
On blood agar: Dry, wrinkled, non-hemolytic colonies.

Gelatin stab agar: Growth appears as an inverted fir tree appearance due to

the liquefaction of gelatin.
Selective media like PLET medium aid in the identification of B. anthracis colonies.
Additional Tests:
Ascoli’s Thermoprecipitation Test: Useful when specimens are putrid. It’s a ring
precipitation test.
Culture Smear:
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.
Spores: Spores of Bacillus anthracis can be demonstrated using hot malachite
green (Ashby’s method).
Molecular Diagnosis:
Polymerase Chain Reaction (PCR): Specific primers can be used in PCR to target
genes associated with B. anthracis.
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53. Write a short note on Varicella zoster infection. (5 marks)
Answer:
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:
Varicella-zoster virus (VZV) enters the body through the upper respiratory mucosa
or conjunctiva via aerosol or contact transmission.
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).
The incubation period for chickenpox is typically 10–21 days (2–3 weeks).
Rashes are the primary manifestation, and they are vesicular in nature.
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.
The distribution of rashes is bilateral and diffuse.
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.
Fever tends to appear with each crop of rashes.
Complications:
Secondary Bacterial Infections of the Skin: These can occur when the skin lesions
from chickenpox become secondarily infected by bacteria.
Central Nervous System (CNS) Involvement: This includes conditions like cerebellar
ataxia, encephalitis, and aseptic meningitis, and it’s more common in children.
Varicella Pneumonia: This is a severe complication that occurs more commonly in
adults than in children.
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.
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.
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Zoster:
Typically occurs due to the reactivation of latent Varicella-Zoster Virus (VZV)
in older individuals (usually over 60 years old), immunocompromised people, or
occasionally in healthy adults.
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.
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.
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:
Post-Herpetic Neuralgia: involves persistent pain at the site of the rash that can
last for months.
Zoster Ophthalmicus: When the eye area is affected, it can lead to painful skin
rashes around the eye.
Ramsay Hunt Syndrome: A triad of symptoms: ipsilateral facial paralysis, ear
pain, vesicles on the face, tympanic membrane, and external auditory meatus.
Visceral Diseases: such as pneumonia,
Recurrent or Chronic Zoster: This is more common in individuals with HIV infection.
Laboratory diagnosis:
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.
Cytopathology (Tzanck Smear): Giemsa staining of scrapings from the base of skin
ulcers (Tzanck smear) can reveal characteristic multinucleated giant cells.
VZV-Specific Methods:
Direct Immunofluorescence Staining: It is useful for direct antigen detection in

clinical specimens.
ELISA (Enzyme-Linked Immunosorbent Assay): ELISA tests can detect specific

IgM and IgG antibodies against VZV in a patient’s blood serum.
PCR is used to detect specific genes of VZV.

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54. Write a short note on measles. (5 marks)
Answer:
Measles is a highly contagious childhood disease caused by the measles virus, which
belongs to the Paramyxoviridae family.
Transmission: Measles is primarily transmitted through respiratory droplets when
an infected person coughs or sneezes. It can also spread through small-particle
aerosols that can remain suspended in the air for longer periods
Pathogenesis:
Local Multiplication: After transmission, the virus initially multiplies in the
respiratory tract of the infected individual.
Lymph Node Involvement: The virus then enters the regional lymph nodes.
Primary Viremia: From the lymph nodes, the virus enters the bloodstream through
infected monocytes, leading to primary viremia.
Reticuloendothelial System: The virus further multiplies in the reticuloendothelial
system
Secondary Viremia: The virus spills over into the blood again which allows the virus
to disseminate to various sites in the body.
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):
This initial stage lasts for about 4 days and typically begins around the 10th day
after infection.
Fever is the first symptom, appearing on day 1 of this stage.
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 second lower molars.
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 5-8):
Maculopapular rashes develop after 4 days of fever, typically on the 14th day
after infection.
The rashes usually start behind the ears and then spread to the face, arms, trunk,
and legs.
They fade in the same order after about 4 days from their onset.
Notably, rashes are typically absent in individuals with HIV infection.
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3. Post-Measles Stage:
This stage is characterized by weight loss and weakness.
Some individuals may fail to fully recover and experience a gradual deterioration
of health, potentially leading to a chronic illness.
Complications:
Giant-cell pneumonitis (Hecht’s pneumonia) in immunocompromised children and
HIV-infected individuals.
Acute laryngotracheobronchitis (croup).
Diarrhea, which can result in malnutrition, including vitamin A deficiency.
Subacute sclerosing panencephalitis (SSPE) is a progressive neurological disorder

and the most important CNS complication associated with measles.
Other CNS complications include post-measles encephalomyelitis and measles
inclusion body encephalitis.
Specimen collection: Casopharyngeal swabs, swabs from the lesions, blood, and
respiratory secretions are taken.
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:
The detection of measles-specific antibodies is an important diagnostic approach.
Measles-specific IgM antibodies can be detected in serum or oral fluid, and a

four-fold rise in IgG antibody titer between acute and convalescent-phase sera is
considered significant.
Demonstration of elevated anti-measles antibody titers in the cerebrospinal fluid
(CSF) is diagnostic of subacute sclerosing panencephalitis (SSPE).
ELISA (enzyme-linked immunosorbent assay) is a commonly used test that employs
recombinant measles nucleoprotein (NP) antigens.
Reverse-Transcription PCR (RT-PCR):
RT-PCR is a highly sensitive and specific method for detecting measles-specific
RNA, such as the nucleoprotein (N) gene.
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55. Write a short note on Rubella. (5 marks)
Answer:
Rubella belongs to the family Togaviridae and is responsible for the disease German
measles.
Transmission and Pathogenesis:
Rubella virus spreads from person to person via respiratory droplets, primarily
through the upper respiratory mucosa.
The virus replicates locally in the nasopharynx before spreading to the lymph
nodes.
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.
The incubation period for rubella is about 14 days, with a range of 12-23 days.
Subclinical (asymptomatic) infections may occur
In children, rashes are often the first manifestation of the disease.
In older children and adults, a 1 to 5-day prodrome may precede the rash,
characterized by low-grade fever, malaise, and upper respiratory symptoms.
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.
Lymphadenopathy (swollen lymph nodes) is a notable feature, particularly in the
occipital and postauricular regions.
Forchheimer spots, pin-head-sized petechiae, may be seen on the soft palate and
uvula, usually coinciding with the onset of the rash.
Complications:
Arthralgia (joint pain) and arthritis (joint inflammation) are common complications
in adults, especially women.
Thrombocytopenia (low platelet count) and encephalitis (brain inflammation) are
rare but possible complications.
Virus isolation: Monkey cell lines
For early detection, we should use a shell vial technique

Serology
ELISA to detect IgM and IgG

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IgG avidity test should be done to differentiate past and active disease.

Molecular test
RT-PCR to detect viral-specific RNA.

PREVENTION
Rubella Vaccine:
The rubella vaccine, often referred to as RA 27/3, is a live attenuated vaccine
prepared from a human diploid fibroblast cell line.
It is available as a single vaccine or in combination with vaccines for mumps and
measles (MMR vaccine).
Vaccination Schedule:
A single dose (0.5 mL) of the rubella vaccine is administered subcutaneously.
Immunity following vaccination typically lasts for 14-16 years, possibly lifelong.
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56. Write a short note on mycetoma? (5 marks)
Answer:
Mycetoma is a chronic granulomatous infection of the subcutaneous tissue.
Types of Mycetoma and Causative Agents:

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.
There is a third category called botryomycosis, which is a mycetoma-like condition
caused by certain bacteria like Staphylococcus aureus.
Pathogenesis:
Mycetoma typically begins when the causative agents enter the skin or subcutaneous
tissue through accidental trauma, such as thorn pricks or splinter injuries.
The disease then progresses slowly, initially forming micro-abscesses due to the
inflammatory response filled with polymorphonuclear leukocytes. These abscesses
are later replaced by chronic granulomatous tissue within the skin and subcutaneous
tissues.
Eumycetoma Actinomycetoma
Black granules: White to yellow granules:
Madurella mycetomatis Nocardia species
Actinomadura madurae
White granules:
Aspergillus nidulans Pink to red granules:
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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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 grains Sulfur 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).
Clinical manifestations of mycetoma are characterized by a specific triad of

symptoms, which include:
Tumor-like swelling (Tumefaction): Refers to localized, abnormal swelling or masses
that develop in the affected area.
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.
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.
The most commonly affected part of the body is feet.
Specimen collection:
Clean the lesion and take the discharge coming from the pus along with granules.
Direct examination:
Clean and crush the granules between slides and examine them.
a. Macroscopic appearance: See the size, shape, and colour of the granule.
KOH mount: Stain the granule and look for chlamydospores
For actinomycetoma: stain with gram stain. Gram +ve bacilli are seen as acid-fast
stains for Nocardia.
Histopath examination: Palisading arrangement of hyphae seen in eumycetoma
while actinomycetoma shows filamentous bacteria.
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Culture:
Granules obtained from deep biopsies are cultured in

Combination of fungal media like Sabouraud dextrose agar (SDA) and bacteriological
media such as Lowenstein-Jensen media should be utilized for culturing.
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

Eumycetoma, antifungal medications like itraconazole or amphotericin B
Actinomycetoma is treated with antibiotics, often following the Welsh regimen,

which combines amikacin with cotrimoxazole.
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57. Write in brief about Rhinosporidiosis. (3 marks)
Answer:
Rhinosporidiosis is a 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.
This condition is caused by Rhinosporidium seeberi, considered an aquatic protistan
parasite rather than a fungus.
Source:
The main source of infection is stagnant water, particularly contaminated ponds
and rivers.
Infection occurs when individuals inhale spores while bathing in these contaminated
water sources.
Specimen: Tissue biopsy of the polyp
Histopathological examination
Revealing distinctive spherules that contain numerous endospores
Mucicarmine stain is effective for visualizing these structures. The primary

treatment for rhinosporidiosis involves radical surgery with cauterization.
Treatment:
Surgery
Dapsone has also shown effectiveness in managing the condition.
The condition is prone to recur.
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58. Write a note on Sporotrichosis. (5 marks)
Answer:
Sporotrichosis, also known as Rose Gardner’s disease, manifests as subcutaneous
noduloulcerative lesions and is caused by a thermally dimorphic fungus called
Sporothrix schenckii.
Pathogenesis
The pathogenesis of sporotrichosis begins with the introduction of S. schenckii
spores into the skin, often through minor injuries like thorn pricks or splinters.
The fungus secretes enzymes, including serine proteinase and aspartic proteinase,
which aid in local tissue invasion.
S. schenckii has a tendency to spread along the lymphatic vessels.
It is a chronic subcutaneous pyogranulomatous disease.
Incubation period of approximately three weeks.
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-like upon palpation.
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 pulmonary disease (COPD).
Disseminated sporotrichosis: 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.
Direct 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.
Histopathological Staining: Tissue sections can be stained, for example, with
hematoxylin and eosin. This staining reveals cigar-shaped asteroid bodies, which
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consist of a central basophilic yeast cell surrounded by radiating extensions of an

eosinophilic mass.
This mass is composed of antigen-antibody complexes and is referred to as the
Splendore-Hoeppli phenomenon. This phenomenon is also observed in other fungal
infections like zygomycosis, candidiasis, aspergillosis, and blastomycosis.
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.
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.
Skin Test: This test may demonstrate a delayed type of hypersensitivity reaction
against the sporotrichin antigen.
Treatment
Itraconazole is the DOC.
Other conditions that show sporotrichoid pattern of spread are:

Nocardia
Mycobacterium marinum
Leishmania brasiliensis
Coccidioidomycosis
Anthrax
Tularemia
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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-smelling discharge from the wound. On
examination, the patient’s right lower leg is swollen and tense, with marked
erythema (redness) and crepitus (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 perfringens.

(C) Write the laboratory diagnosis of clostridium perfringens gas gangrene

Answer:
(A) The probable diagnosis is Gas gangrene. Common causes of this are-
Polymicrobial - most common
Clostridium perfringens- most common among polymicrobial
C.novyi
C.septicum
(B) Pathogenesis: Clostridium produces various toxins which are responsible for its
virulence-
Alpha (α) Toxin: This toxin is responsible for myonecrosis and hemolysis
It has both sphingomyelinase and phospholipids C activity.

It activates platelet adhesion by binding to GpIIb/IIIa and causes vessel occlusion.

Beta (β) Toxin
Epsilon (ε) Toxin: Epsilon toxin affects the central nervous system
Iota (i) Toxin: Iota toxin is involved in causing enteritis necroticans
These are the major toxins responsible for its pathogenesis.
CLINICAL MANIFESTATIONS
Clostridial Wound Infections:
Simple Wound Contamination
Anaerobic Cellulitis: Involvement of the fascial plane with minimal toxin release
and no muscle invasion.
Anaerobic Myositis (Gas Gangrene): Invasion of muscle tissue leading to gas
accumulation in the muscle compartment with significant toxin production.
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Clostridial Enteric Infections:

Food Poisoning: Caused by the type A enterotoxin, typically resulting from
consumption of improperly cooked contaminated meat.
Enteritis Necroticans (Gas Gangrene of the Bowel): A life-threatening condition
involving necrosis of the jejunum and gas in the tissue plane
Necrotizing Enterocolitis
Gangrenous Appendicitis: Involvement of the appendix.
Specimen Collection: Necrotic tissues, muscle fragments, and exudates from the
deeper part of the wound where the infection is more active.
Transport: Specimens should be placed into Robertson’s cooked meat broth and
transported immediately to the laboratory for analysis.
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:
Target Hemolysis: On blood agar, C. perfringens produces a characteristic pattern
of hemolysis with an inner narrow zone of complete hemolysis (due to θ-toxin)
surrounded by a wider zone of incomplete hemolysis (due to alpha toxin).
Nagler’s Reaction: C. perfringens exhibits opalescence surrounding the streak line
on egg yolk agar due to lecithinase activity of α-toxin. This reaction can be
inhibited by incorporating anti-α-toxin into the medium.
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.
Heat Tolerance: C. perfringens can grow in RCM broth incubated at 45°C for 4–6
hours, distinguishing it from other organisms in the specimen.
Litmus Milk Test: C. perfringens produces a “stormy clot reaction” in litmus milk
due to the fermentation of lactose, producing acid and vigorous gas.
Automated Methods: Modern techniques like MALDI-TOF can be used to identify.
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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,
swelling, and severe tenderness at the site. She also mentions that she had a
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:
(A) VIRULENCE FACTORS
Cell wall-associated factors Toxins

Peptidoglycan Membrane active toxins:
Teichoic acid Hemolysins—alpha, beta, gamma, delta
Cell surface adhesins, e.g. clumping Leukocidin (or Panton-valentine toxin)

factor Protein A Epidermolytic toxin (exfoliative toxin)
Enterotoxins Toxic shock syndrome toxin
Extracellular enzymes:
Coagulase
Heat stable thermonuclease
Deoxyribonuclease
Staphylokinase (fibrinolysin)
Others—hyaluronidase, lipase, and

protease
Cell wall-associated factors

Peptidoglycan layer: It is thick, provides rigidity and has endotoxin-like activity.
Teichoic acid: It helps in attaching the cocci to the mucosa and inhibits opsonisation.
Cell surface adhesins: which include bound coagulate, fibronectin binding adhesion
etc.
Protein: A has anti-complementary, inhibits opsonisation and induces platelet
damage
It also binds to the Fc portion of IgG and is responsible for co-agglutination

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

Staphylokinase (Fibrinolysin):
Hyaluronidase:
Lipases and Phospholipases:
PATHOGENESIS OF S. AUREUS INFECTIONS

Colonization:
S. aureus initially colonizes various body surfaces, including the anterior nares
(nose), oropharynx, axilla, and perineal skin.
Introduction to Tissue:
The bacteria are introduced into tissues through minor abrasions or instrumentation.
Adhesion to tissue surfaces is mediated by adhesins such as clumping factor and
collagen-binding adhesion.
Invasion:
S. aureus can invade tissues by producing enzymes like serine proteases,
hyaluronidases, thermonucleases, and lipases.
These enzymes facilitate bacterial survival and local spread within tissue.
Evasion of Host Defenses:
S. aureus employs various mechanisms to evade the host’s immune defenses.
This includes anti-phagocytic activity through microcapsules and protein A,
inhibition of leukocyte migration, and intracellular survival inside endothelial cells.
Metastatic Spread:
S. aureus can spread to distant sites via hematogenous (bloodborne) dissemination.
Common infection caused by S.aureus:
Folliculitis
Carbuncle
Impetigo
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Botromycosis
Abscess
Ventilator-associated pneumonia
Sepsis
Infective endocarditis
Sample Collection:
The choice of the specimen depends on the nature of the infection but commonly
includes pus, wound swabs, sputum, midstream urine, and blood.
For blood cultures, automated blood culture bottles are preferred.
Direct Smear Microscopy:
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:
Nutrient agar- colonies are circular, smooth, convex, opaque, and easily emulsifiable.
Most strains produce golden-yellow non-diffusible pigments.
Blood agar shows colonies similar to those on nutrient agar, often surrounded by
a narrow zone of β-hemolysis.
On MacConkey agar, small pink colonies are produced due to lactose fermentation.
Liquid media like peptone water result in uniform turbidity.
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 Identification:
Catalase Test: Staphylococci are catalase-positive, which distinguishes them from
catalase-negative streptococci.
Differentiating S. aureus from Coagulase-Negative Staphylococci (CoNS):
Coagulase Test: The coagulase test is the most common biochemical test used to
differentiate S. aureus from CoNS.
Detection of Protein A: Protein A is a surface protein found on S. aureus but not
on CoNS. It can also be used for identification.
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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)
Alpha (α)-Hemolysis: Partial lysis of red blood cells (RBCs), creating a small zone
of greenish discoloration surrounding the bacterial colonies.
Beta (β)-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)
Gamma (γ)-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.
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Additional Classification and Typing Methods:

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

Cell Wall Antigens:
Lipoteichoic Acid: Helps in adhesion to pharyngeal epithelial cells and other host
cells and proteins, such as fibronectin.
C-Carbohydrate Antigens: Group-specific antigens that form the basis of Lancefield
grouping.
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.
Capsule: Some strains of Group A Streptococcus are capsulated with hyaluronic
acid, which is antiphagocytic and facilitates colonization.
Toxins:
Hemolysins: Beta-hemolytic streptococci produce two hemolysins, streptolysin-O
and streptolysin-S, which cause RBC membrane lysis, resulting in complete beta-
hemolysis.
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:
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 therapeutically in the treatment of thromboembolic disorders.
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.
(C) CLINICAL MANIFESTATIONS

Suppurative Infections:
Respiratory Infections:
Streptococcus pyogenes is a common cause of pharyngitis (sore throat)
It can lead to infections such as scarlet fever, pneumonia, or empyema.
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Superficial Skin and Soft Tissue Infections:

Impetigo (Pyoderma): A superficial skin infection, primarily caused by Group A
Streptococcus.
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:
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.
Characterized by hypotension with more than 2 organ involvement and streptococcus
positive in blood.
Puerperal sepsis
(D) LABORATORY DIAGNOSIS

Specimen Collection and Transport:
Common specimens include pus swabs, exudates, and blood.
Blood cultures are useful in streptococcal toxic shock syndrome (TSS).
Throat swabs are suitable for diagnosing pharyngitis.
Direct Smear Microscopy:
Gram staining of pus or wound swabs shows gram-positive cocci in chains
Culture:
Specimens are incubated on various media at 37°C with 5–10% CO2.
S. pyogenes is fastidious and primarily grows on media enriched with blood,
serum, or carbohydrates.
Blood agar shows small colonies (0.5–1 mm) with wide zones of β-hemolysis.
Biochemical Tests for Identification:
Catalase test: Streptococci are catalase-negative, distinguishing them from
catalase-positive staphylococci.
Bacitracin sensitivity testing: Group A Streptococcus is sensitive to bacitracin
(0.04 U disk) with a zone of inhibition (useful for rapid diagnosis).
Automation using systems like VITEK and MALDI-TOF can also identify GAS.
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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)

(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
Lepromatous leprosy (LL)
Borderline Lepromatous leprosy (BL)
Borderline leprosy (BB)
Borderline tuberculoid leprosy (BT)
Tuberculoid leprosy (TT)
Characters Lepromatous leprosy (LL) Tuberculoid leprosy (TT)

Bacillary load Multibacillary Paucibacillary
Bacteriological index 4—6+ 0—1 +
Skin lesions Many, symmetrical Margin One or few, asymmetrical

are irregular Lesions that Margin is sharp Lesions
appear as: appear as hypopigmented,
Multiple nodules annular macules with
(lepromata) elevated borders Tendency
towards central clearing
Plaques and xanthoma-
like papules
Leonine facies and
eyebrow alopecia
Nerve lesion Nerve lesions appear late Early anesthetic skin lesion,
Hypoesthesia is a late sign Enlarged thickened nerves,
Variable nerve palsies Nerve abscess seen
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CMI Low Normal
Lepromin test Negative Positive
Humoral immunity Exaggerated Normal
Clinical classification:
Paucibacillary leprosy: Should fulfill all the criteria—(i) 1 to 5 skin lesions, (ii) no
nerve involvement, and (iii) slit-skin smear-negative for lepra bacilli
Multibacillary (MB) leprosy: Should fulfill any one of the criteria—(i) >5 skin lesions;
or (ii) nerve involvement (neuritis); or (iii) slit-skin smear positive for lepra bacilli.
(C) COMPLICATIONS OF LEPROSY

Deformities:
Nerve damage leads to muscle weakness or paralysis.
Direct effects of the disease process, result in issues like facial deformities or
eyebrow loss.
Common deformities in leprosy include:
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),
Hand Deformities: These can manifest as claw hands (abnormal hand posture
resembling a claw) and wrist drop (inability to extend the wrist and fingers).
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 Borderline Lepromatous Lepromatous Leprosy,
and Borderline especially in multibacillary
Tuberculoid leprosy cases
Immunological Basis Delayed-type Immune complex-
Hypersensitivity (DTH) mediated reaction
response against
Mycobacterium leprae
antigens
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Clinical Features Inflammation and Painful and tender nodules

swelling of existing skin or papules on the skin.
lesions.
Systemic symptoms such
New lesions may appear. as fever, malaise, and joint
pain.
Sometimes affects internal
organs.
Histopathological Increased cell-mediated Immune complex deposits

Changes immunity with granuloma in the skin and blood vessels.
formation.
Management Anti-inflammatory Prednisone or other
drugs (corticosteroids) corticosteroids to reduce
to suppress the immune inflammation.
response.
(D)
Smear microscopy is a diagnostic technique used to visualize acid-fast bacilli in
leprosy lesions.
Six samples are collected: four from the skin (forehead, cheek, chin, buttock), one
from the earlobe, and one from the nasal mucosa.
A technique called “slit skin smear” is employed to collect skin and earlobe
specimens. The preferred site is the edge of the lesion.
Biopsy: In some cases, a biopsy from thickened nerves and nodular lesions may be
necessary.
Appearance:
M. leprae is less acid-fast compared to tubercle bacilli. Therefore, Ziehl-Neelsen

staining is used, with 5% sulfuric acid for decolorization.
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 within foamy macrophages known as Virchow’s lepra

cells or foamy cells.
Mouse Foot Pad Cultivation: (footpad of mice or other animals like nine-banded
armadillos)
M. leprae cannot be cultivated in artificial culture media or tissue culture,

making it challenging to follow Koch’s postulates.
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Antibody Detection (FLA-ABS and ELISA):

FLA-ABS (Fluorescent Leprosy Antibody Absorption Test) is widely used to identify
subclinical cases of leprosy.
ELISA detects IgM antibodies to the PGL-1 (Phenolic Glycolipid-1) antigen of M.
leprae.
Test for Detecting Cellular Immunity (Lepromin Test):
At 48 hours (Early or Fernandez Reaction): Induration (>10 mm) at the inoculation
site indicates a delayed-type hypersensitivity (DTH) reaction to the lepra antigen,
suggesting past exposure to lepra bacilli.
At 21 days (Late or Mitsuda Reaction): A nodule of >5 mm size forms at the
inoculation site, which subsequently ulcerates.
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63. Write in detail about superficial fungal infections. (10 marks)
Answer:
Superficial Mycoses
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.
Tinea versicolor presents as flat, round, scaly patches on the skin, with varying
degrees of hypo- to hyperpigmentation
These lesions are non-inflammatory and usually not itchy, although they can
rarely cause itching.
Commonly affects areas rich in sebaceous glands, such as the neck, chest, or upper
arms.
This condition is more prevalent in regions with a humid climate.
Other Manifestations Caused by Malassezia furfur:

Seborrheic Dermatitis: This condition appears as pruritic, erythematous, and scaly
lesions, often referred to as dandruff in adults or cradle cap in infants.
Folliculitis
Atopic dermatitis
Tinea Versicolor:
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.
Culture: Due to the lipophilic nature of Malassezia furfur, culture is performed on
Sabouraud dextrose agar (SDA) with olive oil overlay. After incubating for 5-7
days at, characteristic “fried egg” colonies develop.
Urease Test: A positive urease test can be indicative.
Wood’s Lamp Examination: Under Wood’s lamp, scaly lesions exhibit golden yellow
fluorescence.
Treatment for Tinea Versicolor:
Topical lotions such as selenium sulfide shampoo, ketoconazole shampoo or cream,
and terbinafine cream are typically used for a period of 2 weeks.
Piedra: Piedra is a condition where nodules form on the hair shaft, either black or
white in color.
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White Piedra: White nodules form on the hair shaft, and they are less firmly
attached. This condition is caused by Trichosporon beigelii.
Black Piedra: Characterized by the formation of firmly attached black nodules on
the hair shaft. It is caused by Piedraia hortae.
Dermatophytoses (Ringworm):
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: Infect skin, hair and nail

Microsporum: Infect skin and hair

Epidermophyton: Infect skin and nails.

The classification of dermatophytes is based on their usual habitat:
Anthropophilic: These fungi exclusively infect humans.

Zoophilic: They infect animals and birds.

Geophilic: These fungi are commonly found in soil.

Pathogenesis:
Dermatophyte infections are typically acquired through direct contact with soil,
animals, or humans carrying fungal spores.
These spores can spread to different areas through scratching. Predisposing factors
include moist, humid skin, and tight, ill-fitting clothing.
In 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.
In the nails, they invade through the lateral or superficial nail plates, leading to
brittle nails and areas of alopecia.
Dermatophytes can invade hair shafts, causing brittleness and alopecia. In some
cases, deep and persistent suppurative folliculitis, known as Majocchi granuloma.
Wood’s Lamp Examination:
Some dermatophytes exhibit fluorescence when lesions are examined under a
Wood’s lamp.
This test can be positive for various Microsporum species and Trichophyton
schoenleinii.
The fluorescence is attributed to the presence of pteridine pigment in the fungal
cell wall.
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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:
The collected specimen is mounted in a solution of KOH (10% for skin scrapings
or hair, 20–40% for nail clippings) or calcofluor white stain.
It is then examined for the presence of thin septate hyaline hyphae with
arthroconidia.
In cases involving hair, the arthroconidia may be found on the surface of the hair
shaft (ectothrix) or within the shaft (endothrix).
Culture:
Specimens are inoculated onto Sabouraud dextrose agar (SDA) containing
cycloheximide and incubated for 4 weeks.
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.
Special Hyphae: Dermatophytes typically have thin, septate, and hyaline hyphae.
Hair Perforation Test:

This test is positive for Trichophyton mentagrophytes and Microsporum canis.
Fungi that can perforate hair will produce wedge-shaped perforations.
Urease Test: Trichophyton is urease positive
Molecular Methods:
Polymerase chain reaction (PCR) can be employed to detect species-specific genes,
such as the chitin synthase gene.
Skin Test: This test is used to detect hypersensitivity to dermatophyte antigens,
specifically trichophytin, which can indicate exposure to these fungi.
Treatment
Oral terbinafine or itraconazole are the preferred drugs.
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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: Influenza, coronavirus
Laryngitis Bacterial: S. pyogenes, C. diphtheriae Influenza
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
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Respiratory
65. Enumerate sequelae of streptococcal infection and write in brief about ARF and
PSGN. (3 marks)
Answer:
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

Guttate psoriasis

Reactive arthritis

PANDAS.

Acute rheumatic fever or ARF
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
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, ultimately causing
valve damage.
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
Migratory polyarthritis
Pancarditis
Subcutaneous nodules
Erythema marginatum
Sydenham chorea
Diagnosis of ARF
It is diagnosed using revised Jones criteria with supportive evidence of previous Group
A strep infection by using
Elevated ASO titres
Positive throat culture
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Rapid antigen test for GAS
Recent scarlet fever
PSGN
Post-streptococcal glomerulonephritis (PSGN) is a non-suppurative complication
that arises after an infection with group A streptococci.
In PSGN, antibodies produced against streptococcal antigens cross-react with the
glomerular basement membrane, leading to glomerulonephritis.
PSGN following impetigo typically appears 2–6 weeks after the skin infection,
while PSGN linked to streptococcal pharyngitis emerges 1–3 weeks after the
throat infection.
Pathology
PSGN results from the deposition of antigen-antibody complexes on the glomerular
basement membrane, causing complement activation.
Streptococcal pyogenic exotoxin-B (SPE-B) may play a significant role in the
development of nephritis.
urine retention
renal insufficiency
edema, hypertension
hematuria
pyuria
proteinuria
Diagnosis
Confirmed by elevated levels of streptococcal anti-DNase B antibodies in patients,
which are diagnostic, especially when the titer is above a certain threshold.

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Respiratory
66. Write a short note on non-tuberculous mycobacteria? (5 marks)
Answer:
Nontuberculous mycobacteria (NTM), previously known as atypical mycobacteria
or mycobacteria other than tubercle bacilli (MOTT), form a diverse group of
mycobacteria found in birds, animals, and environmental sources like soil and
water.
While they are opportunistic pathogens occasionally linked to human infections,
there is no known person-to-person transmission.
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

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

produces pigments in the scrofulaceum
dark.
III (Nonchromogens) Slow-growing NTM Mycobacterium avium-
that do not produce intracellulare complex
pigments. (MAC)
Mycobacterium gordonae
IV (Rapid Growers) Rapid-growing NTM Mycobacterium fortuitum

with a growth rate of less Mycobacterium abscessus
than 7 days.
Mycobacterium chelonae
Some important mycobacterium:
M.Marinum: Leads to papules and ulcers known as swimming pool or fish tank
granuloma.
M.scrofulaceum: Leads to cervical lymphadenitis also known as scrofula.
Mycobacterium avium-intracellulare complex (MAC):

Composed of two related organisms: M. avium and M. intracellulare.
These bacteria are opportunistic pathogens, particularly affecting individuals with

HIV infection who have a low CD4 T cell count (typically less than 50/μL).
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.
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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.
Microscopy by ZN staining: Acid-fast bacilli stained with Ziehl-Neelsen (ZN)
staining will appear as red under the microscope. This method helps identify NTM,
but further differentiation from Mycobacterium tuberculosis is necessary.
Culture on LJ media: Löwenstein-Jensen (LJ) media are commonly used for
culturing NTM. Some NTM species grow better on these media, but growth may
vary between species.
Pigment production: LJ media can be incubated in both dark and light conditions
to distinguish between photochromogens (produce pigments only in light) and
scotochromogens (produce pigments even in the dark).
Identification: NTM species can be differentiated from the M. tuberculosis complex
through various methods, including:
Negative result for MPT64 antigen by immunochromatographic tests (ICT),

suggesting NTM infection rather than M. tuberculosis.
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.

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Respiratory
67. Write a short note on EBV infection. (5 marks)
Answer:
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
EBV belongs to the γ sub-family of Herpesviridae. It has double-stranded DNA, is
enveloped, and exhibits icosahedral symmetry.
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
EBV spreads through oropharyngeal contact via infected saliva.
It binds to specific receptors (CD21 or CR2) on B cells, which are also receptors
for the C3b component of complement.
EBV replicates in epithelial cells or surface B lymphocytes of the pharynx and
salivary glands.
Infected B cells become immortalized and produce various immunoglobulins,
including autoantibodies.
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.
Infectious Mononucleosis: This condition primarily affects young adults and is
characterized by:
Headache, fever, malaise

Pharyngitis

Enlarged cervical lymph nodes

Hepatosplenomegaly

Rashes following ampicillin therapy

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Atypical lymphocytosis (CD8 T cells)

Autoantibodies reacting to sheep RBC antigens (detected by the Paul-Bunnell

test)
Malignancies:
Burkitt’s Lymphoma
Nasopharyngeal Carcinoma
Hodgkin’s Lymphoma
Non-Hodgkin’s Lymphoma
Other Conditions Associated with EBV:

Lymphoproliferative Disorder: This occurs in immunodeficient patients, such as
individuals with Duncan syndrome, an X-linked recessive disease affecting young
boys.
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.
Heterophile Agglutination Test (Paul-Bunnell Test):
This tube agglutination test uses sheep red blood cells (RBCs) to detect heterophile
antibodies in the patient’s serum.
An agglutination titer of >256 is considered significant. However, false positives
can occur.
EBV-Specific Antibody Detection:
ELISA and indirect immunofluorescence techniques are commonly used to detect
specific EBV antibodies.
Antibodies to viral capsid antigen (VCA): IgM indicates current infection, and IgG
indicates past infection and immunity.
Antibodies to early antigen (EA): Indicate current viral infection, elevated in
certain malignancies.
Antibodies to EBNA (Epstein-Barr nuclear antigen): Reveal past infection, but a
four-fold rise may suggest current infection.
Detection of EBV DNA (by PCR), or EBV antigens (by direct immunofluorescence
technique) are used in various malignancies and infectious mononucleosis.
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Features Infectious mononucleosis Mononucleosis-like syndrome

Causative agents Epstein-Barr virus CMV, HHV-6, Toxoplasma,
etc
Atypical lymphocytosis present present
Clinical symptoms Fever, myalgia, Similar presentation, except

hepatosplenomegaly, that exudative pharyngitis,
exudative cervical lymphadenopathy
pharyngitis, cervical
lymphadenopathy,
Heterophile antibodies Elevated negative
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68. Write a short note on Pneumocystis jirovecii infection and zygomycosis.
(5 marks)
Answer:
Pathogenesis:
Pneumocystis exists in two forms, cysts and trophozoites.
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.
Trophozoites induce inflammation, recruiting plasma cells and causing frothy
exudate to fill the alveoli, hence it’s also called plasma cell pneumonia.
Clinical manifestations:
Fever: Patients with PCP typically have a high fever.
Cough: A dry, nonproductive cough is common and may progress to a more severe
cough with the production of sputum as the infection worsens.
Shortness of Breath: Breathlessness and difficulty in breathing, especially during
physical activity, are hallmark symptoms.
Chest Pain: Some individuals may experience chest pain, often due to inflammation
and damage to lung tissue.
Weight Loss: Unexplained weight loss is a common symptom.
Night Sweats: Profuse sweating during the night can occur.
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 (GMS) staining is preferred, showing cysts resembling
black crushed ping-pong balls against a green background.
PCR Assay: Developed for detecting specific genes of P. jirovecii.
1, 3 β-D-Glucan: Serum test for detection.
Radiology: Chest X-ray and CT scans may show bilateral diffuse infiltrates. Ground-
glass opacities can be seen at early stages, but atypical manifestations like nodular
densities and cavitary lesions are also reported.
Treatment:
Cotrimoxazole is the DOC
Zygomycosis:
Zygomycosis is a group of severe infections caused by aseptate fungi in the
Zygomycota phylum.
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Respiratory
Rhizopus (R. arrhizus and R. microsporus)
Mucor racemosus
Mucormycosis Pathogenesis:
Spores of these fungi are common in the environment.
Transmission occurs via inhalation, inoculation, or rarely ingestion of spores.
Spores develop into mycelial forms with wide aseptate hyphae, which are
angioinvasive, leading to the spread of infection.
Predisposing factors for Mucormycosis:
Conditions with increased iron load (require iron as a growth factor), such as
diabetic ketoacidosis (DKA).
End-stage renal disease.
Patients taking iron therapy or deferoxamine (an iron chelator).
Defects in phagocytic functions
Clinical Manifestations of Mucormycosis:It can have various clinical presentations,

including
Rhinocerebral: Facial pain, orbital cellulitis and vision loss occurs.
Pulmonary: Dyspnea, cough, chest pain.
Cutaneous form
Gastrointestinal form
Disseminated form
Histopathological staining of tissue biopsies shows broad aseptate hyaline hyphae
with wide-angle branching.
Culture on SDA at 25°C reveals characteristic white, cottony, woolly colonies with
tube-filling growth (referred to as “lid lifters”).
Microscopic examination of colonies shows broad aseptate hyaline hyphae.
Rhizoids: Unique root-like growth arising from the hyphae of certain species of
fungi known as rhizoids.
Rhizopus: nodal rhizoids

Mucor: bsent rhizoids.

Treatment:
Amphotericin B is the DOC
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69. Draw the structure of the Influenza virus and explain the mechanism of generation
of epidemic strains. (5 marks)
Answer:
MORPHOLOGY
Helical Symmetry: These viruses have a helical nucleocapsid structure surrounded

by an envelope.
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.
Site of Replication: The virus replicates its RNA in the nucleus of host cells.
Viral Proteins: Influenza viruses contain eight structural proteins (PB1, PB2, PA,
NP, HA, NA, M1, and M2) and two non-structural proteins (NS1 and NS2).
The polymerase proteins PB1, PB2, and PA are responsible for RNA transcription
and replication.
NP, the nucleoprotein, is a major capsid protein that binds to viral RNA to form
a ribonucleoprotein or nucleocapsid with helical symmetry.
Matrix Proteins:
M1 Protein: This is a major viral protein that forms a protective shell or protein

layer underneath the viral envelope.
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Respiratory
M2 Protein: These proteins function as ion channels in the viral envelope, aiding

in the transport of molecules.
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.

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

strain that is antigenically unrelated to the predecessor strains.
Antibodies developed against previous strains, whether through infection or
vaccination, are often ineffective against the new strain.
Antigenic shift is a significant event that can lead to the emergence of novel
influenza strains with pandemic potential.
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Respiratory
70. Write a short note on Pseudomonas infection. (5 marks)
Answer:
Pseudomonas infections are caused by a group of gram-negative bacteria known
for their ability to resist multiple antibiotics and disinfectants.
Pathogenesis and virulence
Colonization: The infection starts with the bacteria adhering to and colonizing the
host’s surfaces. Factors like pili, fimbriae, and polar flagella aid in adhesion and
movement towards the host.
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
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).
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.
Capsule: Many Pseudomonas strains have a protective polysaccharide capsule that
helps them avoid phagocytosis by immune cells.
Multidrug Resistance
Biofilm Formation
Wide Temperature Range
Healthcare-associated infections like ventilator-associated pneumonia (VAP),
bloodstream infections, urinary tract infections, and surgical site infections, burns.
Chronic respiratory tract infections in individuals with conditions like cystic fibrosis.
Bacteremia leads to sepsis and septic shock.
Infections in various body parts such as the ears, eyes, and skin.
Bone and joint infections, meningitis, and more.
Specimen Collection: Specimens such as pus, wound swabs, urine, sputum, blood,
or cerebrospinal fluid (CSF) are collected based on the suspected site of infection.
Direct Smear: Gram staining of the specimen is performed, which typically shows
numerous pus cells and slender gram-negative bacilli.
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Culture:
Peptone Water: Pseudomonas forms uniform turbidity with a surface pellicle
formation due to higher oxygen tension at the surface.
Nutrient Agar: It results in the formation of large, opaque, irregular colonies with
a metallic sheen, described as iridescence.
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.
Blood Agar: On blood agar, Pseudomonas produces β-hemolytic gray moist colonies.
MacConkey Agar: Pseudomonas colonies on MacConkey agar appear pale and are
non-lactose fermenting.
Selective Media: Cetrimide agar is an example of selective media used to isolate
Pseudomonas from mixed growth in purulent specimens.
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
Identification:
Oxidase and catalase positive
Indole -ve
Catalase +ve
Urease -ve
TSI- alkaline/alkaline with no gas and no H2S.
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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-
M.tuberculosis
M.bovis
Less commonly caused by M.caprae, M.africanum etc.
(B) Virulence and Pathogenesis

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: It is a major structural component of the mycobacterial

cell wall.
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 bacterium acid-fast and resistant to many antibiotics.
Source of Infection:
Human Source: Pulmonary tuberculosis cases in humans are a significant source
of infection.
Bovine Source: Consumption of unpasteurized infected milk can be another source
of infection.
Mode of Transmission:
Airborne
Risk Factors for Transmission:

Sputum Positivity: Patients with positive sputum, indicating the presence of acid-
fast tubercle bacilli, are more efficient at transmitting the disease.
Bacillary Load: Higher bacillary load in sputum, especially in patients with cavitary
lung lesions, increases transmission risk.
Overcrowding: Poorly ventilated, overcrowded rooms facilitate transmission.
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Endogenous Risk Factors for Disease Development:

Low Cell: Mediated Immunity
Comorbid Conditions: Various comorbid conditions like renal transplant, diabetes,

smoking, and more can increase the risk of progression to active disease.
Age and Sex: Young adults and the elderly have an increased risk.
Sequence of Pathogenic Events:

Inhalation: Droplet nuclei containing tubercle bacilli from infected individuals are
inhaled, with only a fraction reaching the alveoli.
Adhesion to Macrophages: Surface molecules like lipoarabinomannan (LAM) on
mycobacteria bind to complement and mannose receptors on macrophages.
Phagocytosis: Macrophages engulf the bacilli, a process enhanced by complement-
mediated opsonization.
Survival Inside Macrophages: Mycobacterial cell wall components, particularly
LAM, impair phagolysosome fusion, allowing the bacilli to survive and replicate
inside macrophages.
Rupture of Macrophages: Eventually, infected macrophages rupture, releasing
bacillary contents to infect other phagocytes, perpetuating the infection cycle.
CLINICAL MANIFESTATIONS
Pulmonary Tuberculosis (PTB):
PTB is the most common form of TB, accounting for 60-90% of all TB cases.
It can be categorized as primary or postprimary (secondary) TB.
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Primary PTB occurs when a person is initially exposed to M. tuberculosis and

typically affects the upper lobes of the lungs.
Postprimary PTB, also known as secondary TB, is a reactivation of latent infection
and usually affects the lower lobes of the lungs.
Symptoms of PTB can include a chronic cough, fever, night sweats, weight loss,
and hemoptysis (coughing up blood).
Extrapulmonary Tuberculosis (EPTB):
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)

Tuberculosis of the central nervous system (meningitis, tuberculoma)

Tuberculous skin lesions (scrofuloderma, lupus vulgaris)

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

The smear is stained using acid-fast stains (ZN stain) and examined under a
microscope.
A positive result shows Mycobacterium tuberculosis as long, slender, beaded, less
uniformly stained red-colored acid-fast bacilli (AFB).
Microscopy provides a presumptive diagnosis, and if a typical AFB appearance is
seen, it is reported as resembling M. tuberculosis.
Advantages: Rapid, easy, and cost-effective.
Disadvantages: Lower sensitivity
Kinyoun’s Cold Acid-fast Staining:
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:
Uses an auramine-phenol solution for staining.
More sensitive than ZN staining, recommended by RNTCP.
The bacilli appear brilliant yellow against a dark background.
Culture Methods:
Considered the gold standard for TB diagnosis.
More sensitive than microscopy.
Detects viable bacilli.
Allows for drug susceptibility testing.
Multiple culture media such as
Lowenstein-Jensen (LJ) medium

MGIT

MPT64 antigen is detected in culture to confirm TB.
Molecular test
PCR: used to detect IS6110, MPT64 and other genes to identify TB bacilli.
GeneXpert (CBNAAT): Rapid test with high sensitivity and specificity and also
detects rifampicin resistance.
Line probe assay: This is used to detect various drug sensitivities of the tubercular
bacilli to aid in treatment.
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72. A 50-year-old female arrived at the emergency room with a persistent dry
cough, high fever (101.8°F or 38.8°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 room 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:
(A)
The most probable diagnosis is Covid-19 infection.

Morphology
It is an enveloped virus with club-shaped proteins attached all around the periphery
of the virus giving it a crown-shaped appearance in electron microscopy.
(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.
Contact Transmission: 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, nose, or eyes.
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:
SARS-CoV-2 enters host cells by binding its spike glycoprotein (S) to the host cell
receptor ACE-2.
This receptor is highly expressed in various tissues, including the lungs, heart,
kidney, and intestine. The virus infects pharyngeal epithelium, leading to influenza-
like illness (ILI) at the early stage.
Development of ILI (Influenza-Like Illness):
COVID-19 often begins with symptoms similar to influenza (ILI) 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):

The leading cause of mortality in COVID-19 patients is hypoxemic respiratory
failure, which can progress to acute respiratory distress syndrome (ARDS).
Factors contributing to ARDS include:
Reduced production of pulmonary surfactants due to damage to type-II alveolar

cells.
Hyperactive muscular movement of inspiration leads to increased lung volume.

Cytokine storm with uncontrolled immune response and elevated proinflammatory

cytokines.
Dilatation of blood vessels, allowing fluid passage and causing pulmonary edema.

Fibrosis and recruitment of fibroblasts in later stages lead to respiratory failure.

Multiorgan failure due to cytokine-induced damage to other organs.

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.
Risk factors for severe disease include age over 60 years and underlying comorbidities
such as diabetes, hypertension, cardiac disease.
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Laboratory diagnosis of COVID-19 involves several methods and considerations:
Specimen Collection and Transport:

Preferred specimens include throat and nasal swabs, collected with appropriate
personal protective equipment (PPE).
Specimens should be properly labeled, packed, and transported while maintaining
the cold chain.
Nucleic Acid Amplification Testing (NAAT):

Real-time RT-PCR is the gold standard for COVID-19 diagnosis.
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).
A sample is considered positive when both screening and confirmatory genes are
detected with a CT value ≤ 40 cycles.
NAAT detects the virus as early as day 1 of symptom onset, peaks around day 5,
and starts to decline by the 3rd week.
Automated Real-time RT-PCR:

Automated platforms like Truenat and CBNAAT are available and have a quick
turnaround time (30-60 minutes).
Antigen Detection:
Rapid antigen tests are available for qualitative detection of specific antigens
(nucleocapsid protein) to SARS-CoV-2.
They are point-of-care tests and provide results within an hour.
Antibody Detection:
IgG antibodies appear about two weeks after infection and can persist.
Antibody tests (ELISA, chemiluminescence, immunochromatographic) are used for

sero-surveillance purposes
Prognostic Markers:
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.
CT scans of the lungs may show characteristic ground-glass appearance and/or
consolidation.
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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 had a 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)

(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 (DT):
Diphtheria toxin is a polypeptide chain consisting of two fragments, A (active) and
B (binding).
Fragment B binds to host cell receptors (e.g., epidermal growth factor), facilitating
the entry of fragment A into the host cell.
Fragment A is the active component responsible for the toxic effects.
Mechanism of Diphtheria Toxin:

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:
The tox gene is carried by a bacteriophage called β-corynephage, and C. diphtheriae
remains toxigenic as long as these phages are present (lysogenic conversion).
Pathogenicity and Clinical Manifestations:
Diphtheria is a toxemia, primarily mediated by the toxin, not bacteremia.
The bacterium remains noninvasive and is localized at the primary site (e.g.,
pharynx), while the toxin spreads through the bloodstream to various organs.
Respiratory Diphtheria:
This is the most common form of diphtheria, affecting the tonsils, pharynx (faucial
diphtheria), nose, and larynx.
The incubation period is approximately 3-4 days.
Faucial diphtheria results in an inflammatory response, leading to necrosis of the

epithelium and exudate formation.
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A leathery grayish-white pseudomembrane forms on the mucosa, composed of

fibrin, neutrophils, RBCs, and bacteria.
It is adherent to the mucosal base and bleeds upon removal.
1. Extension of Pseudomembrane: In 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.
Immediate tracheostomy may be necessary in such cases.
2. Bull-Neck Appearance: Patients with severe diphtheria may develop a “bull-
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:
Cutaneous diphtheria presents as punched-out ulcerative lesions with necrosis, or
rarely, pseudomembrane formation. These lesions are most commonly found on
the extremities.
Systemic Complications:
Diphtheria can lead to various systemic complications, including:
Polyneuropathy

Myocarditis (associated with arrhythmias and dilated cardiomyopathy)

Pneumonia, Pulmonary embolism

Renal failure

Encephalitis, Cerebral infarction

Isolation of Diphtheria Bacilli:
Useful specimens include throat swabs (with fibrinous exudates), portions of
pseudomembrane, or, in some cases, nose or skin specimens.
Gram staining reveals irregularly stained club-shaped gram-positive bacilli
arranged in characteristic patterns.
Albert’s stain, more specific for C. diphtheriae, shows green bacilli with bluish-
black metachromatic granules at the poles.
Culture:
It is fastidious and requires enriched media like blood agar, chocolate agar, and
Loeffler’s serum slope for growth.
Selective media like potassium tellurite agar (PTA) can be used which show black
colonies .
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Toxin Demonstration:
In vivo tests involve inoculating culture broth into guinea pigs, although this method
is rarely used today.
In vitro tests include Elek’s gel precipitation test, which is an immunodiffusion test
that can detect the presence of diphtheria toxin
PREVENTION
Types of Diphtheria Vaccines:
Single Vaccine: Diphtheria toxoid (DT) is a single vaccine. It is prepared by incubating
diphtheria toxin with formalin to inactivate it.
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.

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:
Under the National Immunization Schedule (NIS) of India 2020:
Children receive a total of seven doses, including three doses of the pentavalent

vaccine at 6, 10, and 14 weeks after birth.
Booster doses of DPT are given at 16–24 months and 5 years, followed by

booster doses of Td at 10 years and 16 years.
Pregnant women should also receive two doses of Td at a one-month interval.

Adverse Reactions Following DPT Administration:
Mild: Common adverse reactions include fever and local reactions such as swelling
and induration at the injection site.
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:
Hypersensitivity to a previous dose of the vaccine.
Progressive neurological disorders.
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74. Explain Atypical pneumonia in detail. (10 marks)
Answer:
Atypical pneumonia, also known as interstitial pneumonia, occurs when an
infection affects the interstitial space of the lungs.
Unlike typical pneumonia, cough in atypical pneumonia is characteristically non-
productive.
Common causative agents include:
Respiratory Viruses: This category includes influenza viruses, coronaviruses, RSV,

EBV, adenoviruses, and others.
Bacterial Agents: Mycoplasma pneumoniae
Chlamydiae: Includes Chlamydophila pneumoniae.

Legionella Species

Less Common Bacterial Agents: Coxiella burnetii, Francisella tularensis, and

Orientia tsutsugamushi.
Mycoplasma pneumoniae Legionella
Pathogenesis Attachment: It is mediated by It reach the lungs and

membrane-bound adhesion is 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
Symptoms 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 sites

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
peritoneum, kidneys, skin, and
or SJS)
soft tissues.
Cardiac problems (myocarditis,
pericarditis)
Reactive arthritis
Haematological
complications (anaemia and
hypercoagulopathy).
Mycoplasma pneumoniae
Small Size: Mycoplasmas are among the smallest microorganisms capable of free-
living in the environment. They can be filtered by bacterial filters.
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.

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 β-lactams.
Pleomorphic: Mycoplasmas exhibit high pleomorphism.
Laboratory Diagnosis of Mycoplasma pneumoniae:

Specimen Collection and Transport: Ideal specimens for testing include throat
swabs, nasopharyngeal aspirates, bronchial brushing, bronchoalveolar lavages
(BAL), and lung biopsies.
Culture: It is cultured on PPLO agar, colonies have a “fried egg” appearance.
Antigenic Detection: Several antigenic detection methods are available:
Direct Immunofluorescence Test

Capture ELISA Assay

Antibody Detection in Serum: 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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Molecular Methods: Real-time PCR and BioFire FilmArray Respiratory panel.
LEGIONNAIRES’ DISEASE
Transmission
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.
Human-to-human transmission does not occur.
Laboratory Diagnosis of Legionellosis:

Direct Microscopy:
Gram Stain: Legionellae are poorly stained by Gram stain and can be missed or

appear as faint, pleomorphic, gram-negative rods or coccobacilli.
Other stains Silver Impregnation, Giemsa Stains, direct Immunofluorescence,

Acid-Fast Staining
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 5% CO2 to see growth.
Identification: Species identification of Legionella from colonies can be done through:
Conventional Biochemical Tests.

Automated Identification Systems, such as MALDI-TOF.

Antibody Detection:
Serology: Indirect Immunofluorescent Antibody Test and Enzyme Immunoassays.

Cross-reactivity can occur with other Legionella species.
Urinary Antigen Test: Importantly, prior antibiotic administration does not affect
this test.
Molecular Methods:
BioFire FilmArray: This is an automated multiplex PCR test.

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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 right 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:
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.
Risk factors for invasive aspergillosis include glucocorticoid use, neutropenia,

neutrophil dysfunction, underlying lung diseases (e.g., COPD, tuberculosis), and
anti-tumor necrosis factor therapy.
Depending on the site of involvement, Aspergillus can lead to various clinical
manifestations:
Pulmonary aspergillosis (most common form):
Allergic bronchopulmonary aspergillosis (ABPA)

Severe bronchial asthma

Extrinsic allergic alveolitis

Aspergilloma (fungal ball)

Acute angioinvasive pulmonary aspergillosis

Chronic cavitary pulmonary aspergillosis.

Other forms:
Invasive sinusitis

Cardiac aspergillosis (endocarditis and pericarditis)

Cerebral aspergillosis (brain abscess, hemorrhagic infarction, meningitis)

Ocular aspergillosis (keratitis and endophthalmitis)

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Ear infection (otitis externa)

Cutaneous aspergillosis

Nail bed infection (onychomycosis)

Mycotoxicosis (e.g., aflatoxin-producing A. flavus).

Specimens collected can include sputum and tissue biopsies.
Direct Examination: KOH mount or histopathological staining reveals narrow

septate hyaline hyphae with acute angle branching.
Culture: Inoculate specimens onto Sabouraud dextrose agar (SDA) and incubate at
25°C. Species identification is based on colony appearance.
Antigen Detection:
β-d-Glucan Antigen Assay: A marker of invasive fungal infections.

Galactomannan Antigen: Aspergillus-specific antigen detected by ELISA in

patient’s sera or urine. Useful for early diagnosis.
Antibody Detection: Serum antibody detection is useful for chronic invasive
aspergillosis and aspergilloma.
Skin Test: Positive skin test to Aspergillus antigen extracts indicates hypersensitivity
response and is typically seen in various allergic forms of aspergillosis.
Macroscopic appearance Microscopic appearance of

Aspergillus species
of colony colony (LPCB mount)
A. fumigatus Colonies—smoky green, Vesicle is conical-shaped
velvety to powdery,
Phialides are arranged in
reverse is white
single row
Conidia arise from upper
third of vesicle Conidia are
hyaline.
A. flavus Colonies—yellow green, Vesicle is globular-shaped
velvety, reverse is white Phialides in one or two rows.
Conidia arise from upper
two-third to entire vesicle
Conidia are hyaline.
A. niger Colonies—black, cottony Vesicle is globular-shaped
type, reverse is white Phialides in two rows Conidia
arise from entire vesicle.
Conidia are black in color
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Treatment:
Drug of choice for aspergillosis infection are-

For invasive aspergillosis- Voriconazole
For ABPA- Itraconazole
For chronic pulmonary aspergillosis—Itraconazole
For aspergilloma - Surgery
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CNS
76. What are the infective syndromes of the Central nervous system and the agents
causing it? (3 marks)
Answer:
Routes of infection are:
Hematogenous: enters subarachnoid space via choroid plexus
Direct spread: from adjacent sites like otitis media.
Anatomical defect: like in surgery or trauma
Direct neural spread: In HSV and Rabies virus. These spread along the nerve
Infective Syndrome of CNS
Meningitis Encephalitis SOL Other Infection AES
Suppurative
Focal Brain thrombophlebitis
abscess
Subdural & Infectious myelitis

Epidural empyema
Cystic Parasitic
Toxin Mediated
disease
Meningitis: It is the inflammation of the leptomeninges of the brain with the

involvement of subarachnoid space. Various pathogens lead to meningitis.
Encephalitis: Acute inflammation of brain parenchyma by infectious agents.
Virus: Rabies, herpes, Japanese encephalitis

Parasitic agents: Toxoplasma gondii and Naegleria fowleri.

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
Streptococcus, Bacteroides fragilis, Proteus, E.coli, Staph aureus

Candida, Aspergilla, Cryptococcus

Toxoplasma, Taenia solium.

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Subdural and epidural empyema: Collection of pus below and above the dura
respectively.
Staph aureus and others are similar to brain abscesses
Cystic parasitic disease- Taenia solium.
Approach to a patient with probable CNS infection:

Take proper history
High-grade fever, neck rigidity, photophobia, and projectile vomiting point

towards acute meningitis
Fever with weight loss, cranial nerve palsies, cough, and decreased appetite point
towards tubercular or other chronic forms of meningitis
Behavioural changes, seizures, and altered sensorium point towards encephalitis
as a cause.
A triad of high-grade fever, focal neurological deficits and severe headache point
to a focal brain abscess.
Examination:
Look for Kernig and Brudzinski sign for meningitis
Cranial nerve involvement or stroke-like features seen in tubercular meningitis
Focal neurological deficits in localised brain abscess
Investigation:
CSF study
Blood cultures
Sputum analysis for TB
MRI and CT scan
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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)
Encephalitis is an acute inflammation of the brain parenchyma caused by the
invasion of infectious agents majority are viruses.
The causes of encephalitis are

Herpesvirus
HSV1>HSV2

CMV

HHV6

Varicella virus

EBV

Arboviruses
JE

West Nile virus

Rabies
Nipah and Hendrix virus. etc.
(B) Clinical features of encephalitis
In 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.
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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.
Viral markers in CSF are identified using PCR
Antibodies detection in CSF by ELISA
(C) JE virus is the most common cause of vaccine-preventable encephalitis in India.
It is an ssRNA virus belonging to the family Flaviviridae and its vector is the Culex
mosquito.
Transmission cycle of JE virus:
Two transmission cycles are predominant
Animal Host: JE virus has 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.

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.
The prodromal stage is a febrile illness. Onset is either sudden (1-6 hours), acute
(6-24 hours), or more commonly subacute (2-5 days).
Acute encephalitis stage: JE is the most common cause of acute encephalitis syndrome
(AES) in India which is characterized by acute fever, confusion, disorientation,
delirium, seizures, or coma.
IgM Capture Antibody (MAC) ELISA
RT-PCR detect the JE virus-specific envelope gene (E) in blood.
Treatment:
Supportive measures only
Preventive measures:
Live attenuated SA 14-14-2 vaccine
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78. Write a short note on Acanthamoeba encephalitis. (5 marks)
Answer:
Introduction
Acanthamoeba species are free-living amoebas that infect the central nervous
system, skin, and eyes.
They are isolated from soil, fresh and brackish water.
Morphology
It occurs naturally as cysts and trophozoites form.
There are no flagellated forms.

Trophozoites: 30 μm 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.
Cysts: 10–25 μm in size, double-walled, outer wall of cyst wrinkled appearing.
Life cycle and etiology

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.
Trophozoites enter the CNS via the hematogenous route from the lungs.
These cause two important clinical syndromes.
GAE (granulomatous amebic encephalitis) in immunocompromised patients,

Keratitis in contact lens wearers

Granulomatous amebic encephalitis (GAE)
GAE begins insidiously, with incubation periods that vary from weeks to months.
Pathology: Focal granulomatous lesions develop in the brain. CSF lymphocytosis
may be observed. However, no cells are found in the CSF of AIDS patients.
Symptoms: Confusion, dizziness, nausea, headache, stiff neck, and sometimes
seizures and hemiplegia.
In HIV patients: In addition to GAE, Acanthamoeba causes nasal ulcers, skin ulcers,
and musculoskeletal abscesses.
CSF Microscopy: CSF is the specimen of choice for GAE.
The presence of characteristic trophozoites (or sometimes cysts) confirms the

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

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Permanent staining: performed on CSF and brain biopsies H&E staining or PAS
staining. The characteristic morphology of trophozoites can be observed.
Calcofluor staining to visualize double walled cysts.
IFAT with specific antisera can be used to identify Acanthamoeba species.
Culture: Clinical specimens are plated on sterile agar medium supplemented with
bacteria and incubated at 30°C. However, unlike Naegleria, Acanthamoeba is not
easily isolated from culture.
Molecular methods: Multiplex real-time PCR can be used
Imaging methods: CT scan or MRI show space-occupying or ring-enhancing lesions

in the brain.
Treatment
Unfortunately, there is no proven effective treatment for this disease.
Suggested combination therapies include pentamidine, azoles, sulfonamides (such

as co-trimoxazole), and possibly flucytosine.
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79. Write a short note on Naegleria fowleri infection. (5 marks)
Answer:
Naegleria fowleri infection:
Naegleria is a free-living amoeba commonly found in warm freshwater bodies such
as ponds, lakes, rivers and pools.
It occurs naturally in the form of cysts and trophozoites
Trophozoite stage: There are two forms:
Amoeba-like morphology: found in humans.

Flagellated form: When the amoeba is exposed to distilled water, it transforms

into Flagellate form.
Cystic stage: The cyst is 7–15 µm in size and is surrounded by a thick, smooth
double wall. It occurs within the environment
Amoeboid trophozoites :
The size is around 20 µm with granular cytoplasm containing phagosomes.
The nucleus contains a large central karyosome and no peripheral chromatin.
There are lobular pseudopodia (called lobopodia)
Life cycle and virulence:

Infectious form: The amoeba-like form is both an invasive and a common infectious
form of the parasite.
Mode of transmission: People become infected through nasal contamination when
swimming
CNS invasion: Amoeboid form invades the nasal mucosa and migrates along the
olfactory tract that reaches the brain. Penetration initially causes significant
necrosis of the nasal mucosa and olfactory bulbs.
Tissue destruction is primarily mediated by two mechanisms.
Direct ingestion of brain tissue by amoebostome

By contact-dependent cytolysis mediated by hemolytic proteins, cytolysins, and

phospholipase enzymes.
Primary amebic meningoencephalitis:
It causes an acute fulminant suppurative infection of the CNS known as PAM.
Incubation period: 1-2 days to 2 weeks after exposure. The clinical course is acute
and fulminant.
Early symptoms include changes in taste and smell (due to involvement of the
olfactory nerve), followed by headache, anorexia, nausea, vomiting, high fever,
and even signs of meningeal damage such as stiff neck and positive Kernig sign.
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Secondary symptoms include confusion, hallucinations, inattention, ataxia, and

seizures.
CSF analysis: CSF is thick and purulent, increased protein, and decreased sugar
levels (mimicking bacterial meningitis)
CSF microscopy: Characteristic trophozoites confirms the diagnosis. No cysts seen.
Histopathology: Staining of biopsied brain tissue with H&E and Giemsa stains can
reveal trophozoites with sky blue cytoplasm and pink nuclei
Culture: CSF samples were grown on non-nutrient agar, with bacterial supplements
such as E. coli.
Molecular methods: Multiplex real-time PCR is available.
Imaging methods: CT scans and MRI
Treatment:
Amphotericin B
Other drugs such as rifampicin, sulfisoxazole, and antifungal drugs such as

miconazole, fluconazole, and miltefosine have also been shown to be effective.
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80. Write a short on cryptococcal meningitis. (5 marks)
Answer:
A major cause of chronic fungal meningitis is Cryptococcus other fungal infections
rarely involve CNS
Introduction:
Cryptococcal meningitis is caused by an encapsulated yeast called Cryptococcus
neoformans, which can cause fatal meningitis in HIV-infected persons.
Species and Serotypes: Cryptococcus has two species, C. neoformans and C. gattii,
and four serotypes, A, B, C, and D.
Pathogenesis:
Infection is acquired by inhalation of aerosolized forms of Cryptococcus. Both yeast
cells as well as basidiospores are infectious.
In people with low immunity, pulmonary infection occurs followed by dissemination
through the blood
CNS spread: The unique feature of Cryptococcus is its ability to cross the blood-
brain barrier which occurs by the yeast cells either they migrate directly across
the endothelium or are carried inside the macrophages
Virulence factors of Cryptococcus that favor invasion and spread of infection
include:
Polysaccharide capsule: It is the principal virulence factor of the fungus. It is

antiphagocytic and also inhibits the host’s local immune responses Ability to
make melanin by producing an enzyme called phenyl oxidase Production of
other enzymes such as phospholipase and urease.
Risk factors: Individuals at high risk for cryptococcosis include:
Patients with advanced HIV infection with CD4 T cell counts less than 200/µL:

They are at high risk of acquiring C. neoformans infection.
However, C. gattii is not associated with HIV infection. It usually causes infection

in immunocompetent individuals Patients with hematologic malignancies
Transplant recipients
Patients on immunosuppressive or steroid therapy.
Pulmonary cryptococcosis: It is the first and the most common presentation
Cryptococcal meningitis: It presents as chronic meningitis, with headache, fever,
sensory and memory loss, cranial nerve paresis and loss of vision (due to optic
nerve involvement)
Skin lesions
Osteolytic bone lesions.
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Specimens such as CSF, blood or skin scrapings can be collected.

Direct Detection Methods Negative staining:
Modified India 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 cells against a black background Capsules
may be twice as thick as the diameter of yeast cells India ink stain is less sensitive
(60–70%).
Gram staining may show gram-positive round budding yeast cells
Other stains include:
Mucicarmine stain: It stains the carminophilic cell wall of C. neoformans

Masson-Fontana stain: It demonstrates the production of melanin

Alcian blue stain to demonstrate the capsule.

Antigen detection: The capsular antigens can be detected from CSF or serum by
latex agglutination test.
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 is present it’s colonies appear as mucous creamy white in nature.
Confirmation
Bird seed agar and Niger seed agar

Urease test positive

Inositol and nitrate assimilation

MALDI-TOF

Pathogenicity test in mouse

Treatment:
Without CNS involvement- Fluconazole
Immunocompromised with CNS involvement-
induction phase of 2 weeks of AmphoB along with fluticasone

continuation phase with fluconazole

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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 h/o She had stepped on a rusty
nail a week ago, didn’t seek medical care, and wound became infected.
(10 marks)
(A) What is 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
specimen is more reliable than a swab from the wound pus
Staining: Gram stain reveals gram-positive bacilli which have a terminal spore
giving ita drumstick appearance
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.
Toxin assays: In Vivo mouse inoculation test
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(B) PATHOGENESIS
Clinical features:
These are mostly due to increased activation of lower motor neurons therefore
present as stiffness.
Trismus or lock jaw is the first symptom while in neonates it is difficulty in feeding.
It slowly progress descending spastic paralysis
The DTR are exaggerated.
Autonomic disturbances can also occur
Complications:
Risus sardonicus: sustained spasm of the masseter muscle giving a grinning look
on face
Opisthotonos: Due to generalised extensor muscle spasm there is abnormal body
posture
Death due to spastic paralysis of diaphragm.
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(C) TREATMENT
Passive immunisation:
HTIG (human tetanus immunoglobulin)

ATS (anti tetanus serum) derived from horse.

Dosage is 250 IU of HTIG single dose IM . Effect last for 30 days.
Combined immunisation- Give both active and passive immunisation i.e. TT with
HTIG
Other supportive measures to sustain breathing and respiration by endotracheal
intubation
Wound treatment by surgical debridement.
Prevention of tetanus:
By giving active immunisation: TT or tetanus toxoid is the inactivated form of the
main virulent exotoxin of the bacteria.
In children given in combination as DPT while in adults as Td
It is given IM at thigh anterolateral aspect in children and on deltoid in adult.
It is also known as 8th day disease where neonates looses ability to suck and cry.
It should be promptly identified and treated.
The neonate should be vaccinated according to the NIS.
Tetanus schedule under NIS is:

3 doses in pentavalent at 6, 10, 14 weeks of age
2 booster dose of DPT at 16-24 weeks and at 5 years of age
Two dose of Td at 10 and 16 years of age.
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82. A 36yr old male presented to the OPD with complaints of new onset epilepsy.
He has no history of trauma. No metabolic abnormality is present and CBC LFT
and KFT all are within normal limits. On CT brain the doctor sees starry sky
appearance and makes a diagnosis of X. (10 marks)

(B) What is the life cycle Pathogenesis and clinical features of the organism

responsible ?

(C) What is the laboratory diagnosis?

Answer:
(A) The diagnosis is Neurocysticercosis due to its characteristic CT finding of starry
sky appearance.
(B) This disease is caused by the parasite Taenia solium
Life Cycle:
Hosts: Humans serve as both definitive and intermediate hosts.
Infective Form: T. solium egg.
Mode of Infection: Humans become infected by ingesting:
Contaminated food or water containing eggs.

Autoinfection, which can occur through two types:

External self-infection, often due to unsanitary personal habits.

Internal self-infection, where reverse peristalsis pushes eggs back into the

stomach. A past episode of intestinal tapeworm is necessary for autoinfection
to develop.
Human Cycle: Embryos or oncospheres are released from the egg, enter the
intestine, then the portal circulation or mesenteric lymphatics, and proceed to
various organs such as subcutaneous tissue, muscles, eyes, and the brain, where
they develop into cysticerci. It takes two to three months for full development.
Cysticercus cellulosae:
Adult cysticerci are spherical, pale yellow, 5 mm long, and 8-10 mm wide.
They are separated from host tissue by a thin collagenous capsule.
They consist of two chambers: an outer bladder-like sac filled with 0.5 mL of
follicular fluid and an inner chamber containing the growing scolex.
Clinical Features:
Cysticercosis: Clinical presentation depends on the location of cysts, which can
be found throughout the body, with common sites including the central nervous
system, subcutaneous tissue, skeletal muscle, and eyes.
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Neurocysticercosis (NCC): Accounts for 60-90% of cases, is the most common

form, and is a major cause of adult epilepsy worldwide. It primarily affects adults
between 30 and 50 years old and can be parenchymal or extraparenchymal.
Symptoms of NCC: Seizures (70% of cases), hydrocephalus, increased intracranial
pressure, headache, vomiting, dizziness, chronic meningitis, focal neuropathy,
mental disorders, dementia, cerebral arteritis (with subarachnoid cyst), and basal/
ventricular involvement.
NCC Stages: Vesicular, necrotic, nodular, and calcified stages.
NCC and HIV: Co-infection with HIV is increasingly likely and should be recognized
in HIV patients.
Other Forms of Cysticercosis:
Subcutaneous Cysticercosis: Often asymptomatic, may present as palpable nodules.
Muscle Involvement: Manifests as muscle pain, weakness, or pseudohypertrophy.
Ocular Cysticercosis: Affects eyelids, conjunctiva, and sclera, causing symptoms

like proptosis, double vision, vision loss, and slow-growing nodules with localized
inflammation.
(C) Laboratory Diagnosis
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.
Histopathology: Cysticerci can be detected in muscle, eye, subcutaneous tissue,
or postmortem brain through surgical removal or biopsy following fine needle
aspiration. Microscopic imaging distinguishes viable, necrotic, and calcified cysts.
Fundoscopy: Visual confirmation of larval movement and morphology.
Treatment:
Parenchyma Lesions: Treated with Albendazole or Praziquantel.
Symptomatic Treatment: Includes anti-epileptic medication for epilepsy and

steroids to reduce brain inflammation, preventing hydrocephalus.
Surgery: Generally not performed.
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83. Write a short note on bacterial meningitis. (10 marks)
Answer:
Definition: Acute bacterial meningitis is an acute onset purulent infection in the
subarachnoid space characterised by increased polymorphonuclear cells in the CSF.
Predisposing factors: Age group, CSF shunts, BBB integrity and immunization
Causative agents of acute meningitis:

Bacterial: Streptococcus pneumoniae, Neisseria meningitides, Haemophilus
influenza, E.coli, Streptococcus agalactiae, Listeria monocytogenes,
Viral: Enterovirus, Herpes virus etc
Parasitic: Naegleria fowleri.
Causative agents of chronic meningitis:

Bacterial: Tuberculosis, Borreliosis, Syphilis, Tropheryma whipplei.
Parasitic: Acanthamoeba, NCC
Fungal: Candida and Cryptococcus.
Clinical features:
High Fever: Sudden onset of high fever, often accompanied by chills.
Severe Headache: Intense, throbbing headache that can be accompanied by neck

stiffness.
Neck Stiffness: Difficulty in flexing the neck forward due to inflammation of the
meninges.
Photophobia: Sensitivity to light, which can cause discomfort or pain in well-lit
environments.
Nausea and Vomiting: Many patients experience nausea and vomiting due to the
severe headache.
Confusion or Altered Mental State: Patients may become disoriented or confused,
especially as the infection progresses.
Skin Rash: In some cases, particularly with Neisseria meningitidis infections, a
distinctive skin rash may develop.
Clinical signs:
Kernig’s: Kernig’s sign involves pain and resistance when extending the leg at the
knee while the hip is flexed.
Brudzinski’s Sign: It is the involuntary flexion of the hips and knees when the neck
is passively flexed.
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Approach to a patient:
CSF study in meningitis:
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Streptococcus pneumoniae
Culture: a-hemolytic colonies on blood agar, k/a draughtsman-shaped or carrom

coin appearance
Biochemical test: bile soluble, ferments inulin and optochin sensitive

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.
Haemophilus influenza
Culture: Blood agar with S. aureus shows satellitism.

Biochemical test: factor requirement growth surrounding combined X and V

disk
Streptococcus agalactiae
Culture: β-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

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
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 (β-hemolytic colonies), and chocolate agar.

Selective media such as PALCAM agar (containing a mixture of antibiotics) may
be useful.
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TREATMENT
Empirical therapy
Adults: IV cefotaxime and vancomycin
Neonates: IV ampicillin with gentamicin
Dexamethasone may be added to reduce ICT
Definitive based on culture and sensitivity report
Chronic meningitis
Tubercular meningitis: It is seen after pulmonary TB hematogenous spreads to the
meninges and the brain parenchyma.
Clinical features- symptoms of meningitis are there along with cranial nerve

palsies and stroke due to vasculitis occurring in the late stage.
LabD- CSF study Cobweb coagulant formation of CSF if kept for 12 hrs.

Acid- fast staining reveals bacteria in CSF but sensitivity is low

CSF culture can be done on LJ medium or MGIT. These are sensitive test

Genexpert has high sensitivity and specificity.

Tuberculoma: It’s a space-occupying focal brain abscess in the cortex of the brain.
MRI and CT show a contrast-enhancing lesion.
Neurosyphilis: It is tertiary syphilis that can cause vasculitis and neuropathy in
the brain known as paresis—defects in personality, affect, reflexes (hyperactive),
eye (e.g. Argyll Robertson pupils), sensorium (illusions, delusions, hallucinations),
intellect (recent memory loss), and speech.
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84. A 4-year-old boy, was brought to the emergency department by his parents
with complaints of sudden onset muscle weakness in both legs. The parents
noticed that their son had a fever and sore throat about a week ago, which
resolved on its own. However, he began having difficulty walking and standing in
the days following the fever. The boy is not vaccinated. Upon examination, the
boy had notable muscle weakness in both legs, especially in the left leg. His left
leg appeared thinner than the right, and he had reduced muscle tone. Reflexes
were diminished in both legs. No other neurological abnormalities were detected.
(A) What is the likely diagnosis?

(B) What are the various causes of viral meningitis and myelitis?

(C) Write the Pathogenesis, clinical manifestation and laboratory diagnosis of
the causative organism. (10 marks)

Answer:
(A) The probable diagnosis is poliomyelitis caused by poliovirus.
(B) Common causative agents of viral meningitis are-
Enterovirus: in >85% of cases mainly Coxsackieviruses, Echovirus etc
Herpes virus: HSV,VZV,EBV
Arbovirus
LCM: lymphocytic choriomeningitis virus.
Other viruses like measles, mumps HIV
Common causative agents of viral myelitis are:

Gray matter myelitis: Mainly caused by poliovirus, echovirus, and some arboviruses
like West Nile virus, JE virus
Transverse myelitis: or white matter myelitis is caused by Herpesvirus, influenza,
HIV and HTLV.
(C) Polio is a very disabling infection of the pediatric age group responsible for sudden
onset flaccid paralysis.
Morphology of polio:
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Pathogenesis:
Poliovirus is transmitted by the fecal-oral route (most common), followed by
respiratory droplets from inhalation or, rarely, by contact with the conjunctiva.
Local proliferation: It proliferates in intestinal epithelial cells, submucosal lymphoid
tissue, tonsils, and Peyer’s patches.
Receptor: Virus entry into the host cell is mediated by binding to the CD155
receptor on the host cell surface.
CNS/Spinal Spread:
Hematogenous spread (most common):
Nerve spread: Viruses can also spread directly through nerves. This is especially
true after tonsillectomy,
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.
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

Asymptomatic infection: After infection, the majority of cases are asymptomatic.
Abortion infection: Some of the patients have mild symptoms such as fever,malaise,
sore throat, loss of appetite, muscle pain, and headache.
Non-paralytic polio: Aseptic meningitis is seen in 1% of patients,
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
to the extremities. This leads to the characteristic tripod sign.
Biphasic course: In children, the course of the disease is usually biphasic. Aseptic
meningitis initially develops → resolves → fever with paralytic symptoms recurs
1-2 days later
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).
Virus isolation from CSF or blood is very rare. Transport: Specimens should be kept
frozen during transport to the laboratory.
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.
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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.
Antibody Detection Elevated antibody titers in paired sera collected one to two
weeks apart are indicative of polio.
Molecular methods: Real-time multiplex reverse transcriptase PCR was developed
using primers for the VP1 region.
Polio vaccine:
Polio vaccine Injectable vaccine (Salk) Oral vaccine (Sabin)

Formulations IPV contains three Trivalent OPV
serotypes 1, 2 and 3 (serotypes 1, 2 and 3)
Bivalent OPV (serotype
1 and 3)
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 Zero dose—given at
(intra-dermal route at birth
upper arm, 0.1 mL/dose):
1st, 2nd and 3rd
Given at 6th and 14th
weeks of age along with dose —given at 6th,
bivalent OPV 10th, 14th week of
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
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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 is the likely diagnosis?

(B) What is the Pathogenesis, clinical features and laboratory diagnosis.

(C) What are pre and post exposure prophylaxis measures? (10 marks)

Answer:
(A) The probable diagnosis is Encephalitic rabies caused by rabies virus.
(B) Morphology
Bullet shaped RNA virus
G protein are most important as responsible for the Pathogenesis of the virus as
well as used in vaccine development.
Transmission:
Animal Bite: Most cases are due to dog bites. Other are bat foxes etc.
Non bite exposure: Direct contact with infected mucosa or inhalation of virus or
corneal or organ transplantation.
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Virus spread:
Local replication: The virus begins to multiply locally at the site of inoculation in
muscle or connective tissue.
Viral entry into peripheral neurons: The virus binds to nicotinic acetylcholine
receptors at the neuromuscular junction.
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.
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 viremia.
Salivary shedding
Pathological changes: The presence of Negri bodies (cytoplasmic eosinophilic
inclusion bodies) composed of rabies virus protein and viral RNA
Incubation period is long and variable, averaging 20-90 days.
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.
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
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.
A period of hyperexcitability is usually followed by complete lucidity,
Autonomic dysfunction such as lacrimation, salivation sweating, goose bumps,
arrhythmia, and priapism may also occur.
Hydrophobia (fear of water) or aerophobia (fear of air): Paralytic or dull rabies:
This occurs especially in partially vaccinated people or those infected with the bat
rabies virus. It is characterized by flaccid paralysis.
Coma and death.
Antigen Detection by Direct Immunofluorescence (Direct-IF): The DFA test is
considered the “gold standard” method for diagnosing rabies due to its high
sensitivity and specificity. The best sample is the hair follicles on the back of the
neck (the most sensitive).
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Virus-isolated in mice
Cell lines: Mouse neuroblastoma cell lines and baby hamster kidney (BHK) cell lines
are the preferred cell lines for rabies virus isolation
Antibody Detection: In CSF is more significant than serum antibodies. Serum
antibodies appear late and can also be present after vaccination by IFA, mouse
neutralisation test.
Viral RNA Detection-RT-PCR can be used
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.
Prevention is the most important way of curtailing this disease.
Rabies vaccines:
Purified chick embryo cell vaccine: It is prepared from chicken fibroblast cell line
Purified Vero cell (PVC) vaccine
Human diploid cell (HDC) vaccine
Pre-exposure prophylaxis:
Regimen for PrEP- can be given to individuals of all ages. Schedule: Two schedules
are available
2-site ID vaccine given on days 0 and 7
1-site IM vaccine given on days 0 and 7.
Booster: PrEP is likely to provide lifetime protection
Post exposure prophylaxis:
PEP regimen schedule:

ID PEP regimen (2-2-2): 2-site ID vaccine is given on days 0, 3 and 7
IM PEP regimens: Total four doses are given. Two schedules are available
1-site IM vaccine given on days 0, 3, 7 and the fourth dose between days 14

to 28 or
2-site IM vaccine given on day 0 and 1-site IM on days 7 and 21.

Rabies immunoglobulin (RIG):
These provide passive immunity and can be administered with 7 days of first dose
of vaccine
These antibodies directly neutralise the virus.
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86. Write short notes on: (10 marks)
(A) Toxoplasma encephalitis (5)

(B) Prions disease (5)

Answer:
(A) INTRODUCTION
Toxoplasma gondii is an obligate intracellular parasite.
Human infections are common, but cause disease in HIV/AIDS (leads to encephalitis)
and congenital infections in the fetus.
Morphology
It has 3 morphological forms, two asexual forms (tachyzoites and tissue cysts) and
one sexual form(oocysts).
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.
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 trophozoites.

Oocyst is the sexual form of the parasite found in cats.

Lifecycle
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CNS
PATHOGENESIS
Various risk factors for infections include:
Immune status: Patients associated with HIV, malignancies, other immunodeficiency
diseases are at high risk.
Diet: Consumption of raw cat meat.
High risk Genetic factors: HLA DQ3 is associated with encephalitis in AIDS patients
and hydrocephalus in Toxoplasma-infected fetuses.
Immunocompetent: It is usually asymptomatic and self-limited.
Lymphadenopathy: The most common symptom is cervical lymphadenopathy.

Other lymph nodes may also be affected.
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Toxoplasmosis in HIV patients infection occurs as a result of reactivation of latent

infection. It causes Toxoplasma encephalitis (TE).
Toxoplasma encephalitis:
It affects brainstem, basal ganglia, pituitary gland, and corticomedullary junction.
Patients experience altered mental status, seizures, paresthesias, cerebellar

symptoms and focal neurological deficits.
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.
Tissue cyst containing strongly PAS positive bradyzoites can be detected in various
tissues like brain or muscle.
Antibody detection: remains the most widely used method for diagnosing acute
toxoplasmosis in immunocompetent persons.
IgG antibodies: Diagnosis of acute toxoplasmosis requires a 4-fold increase in

IgG titer.
IgG avidity test: The avidity of IgG and its antigen increases over time.Evidence

of low IgG avidity indicates recent infection (less than 12 weeks).On the other
hand, strong avidity indicates previous infection.
IgM 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.
Simultaneous IgG and IgM tests are interpreted as follows:
IgG (+) and IgM (+): indicate acute infection, but require further confirmation

by IgG avidity test.
IgG (+) and IgM (-): indicate T.gondii >6 months ago (remote infection)

IgG (-) and IgM (+): indicates false positive IgM.

Sabin-Feldman Dye Test- This is a complement-mediated neutralization test that
requires live tachyzoites.
Molecular diagnostics: PCR can be used to detect DNA
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.
CSF Testing: Increased ICP, lymphocytosis, slightly elevated protein concentrations,
occasionally elevated levels of gamma globulin, and normal blood glucose levels.
(B)
Prions: Infectious protein particles devoid of nucleic acids.
Resistant to Sterilization: Prions are resistant to chemical and physical sterilants.
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CNS
Prion Diseases: Exist in humans and animals.
Mechanism:
Prions induce misfolding of normal cellular prion protein (PrPC) to form the
disease-causing isoform (PrPSc).
PrPSc aggregates as amyloid-like plaques in the brain.
Taken up by neurons and accumulates in cytoplasmic vacuoles.
Leads to spongy appearance in cells, inherited by offspring.
Clinical Features:
Incubation period varies (months to up to 30 years).
Rapid disease progression.
Prodromal phase (3-5 months), followed by symptoms: loss of muscle control,

tremors, myoclonic spasms, coordination loss, and dementia.
Death within a year of disease onset.
Human Prion Diseases:
Kuru: Spread through ritual cannibalism of infected deceased relatives.

Creutzfeldt-Jakob Disease (CJD):
Most common human prion disease.
Associated with dementia and myoclonus.
Progressive and usually fatal within a year.
Types:
Classical or sporadic (85% of cases): Spontaneous misfolding.

Familial (15% of cases): Inherited mutations.

Variant (vCJD): Develops before age 30

Measurement of PrPSc by conformation-dependent immunoassay.
Neuropathological diagnosis on brain biopsy: Spongiform degeneration without

inflammatory response.
Abnormal EEG: Shows late-phase sharp, high-voltage discharges.
Treatment:
No available treatment for prion diseases.
Edition, Page No. 731, 725
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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
Escherichia coli: Most common Candida albicans
Klebsiella pneumoniae
Enterobacter species
Proteus species
Serratia species
Non-fermenters
Pseudomonas aeruginosa
Acinetobacter species
Gram-positive bacilli Parasites
Mycobacterium tuberculosis Schistosoma haematobium
Trichomonas vaginalis
Dioctophyme renale
Gram-positive cocci Viruses

Enterococcus species BK virus
Staphylococcus species Adenovirus
Laboratory diagnosis of UTI:
Proper specimen collection is crucial for accurate diagnosis of UTIs.

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 males) before providing the urine sample.
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.
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Urogenital infections
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
catheter)

Transport and Examination of Urine Samples:
Urine samples should ideally be processed immediately after collection.
If there’s a delay of more than 1-2 hours before processing, the sample can be
stored in the refrigerator.
Another method for longer storage (up to 24 hours) is by adding boric acid to the
urine sample.
Direct Examination (Screening Tests):
Wet Mount Examination: This test aims to demonstrate the presence of pus cells
in urine.
Leukocyte Esterase Test: This detects leukocyte esterases produced by pus cells in
urine.
Nitrate Reduction Test (Griess Test): It identifies nitrate-reducing bacteria like E.
coli. A positive result indicates the presence of these bacteria.
Gram Staining:
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.
Gram staining may be limited to cases of pyelonephritis and invasive UTIs, where
a count of ≥1 bacterium per oil immersion field is considered significant.
Culture:
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.
The concept of “significant bacteriuria” is based on a count of ≥10^5 colony-
forming units (CFU)/ml of urine, indicating infection. Counts between 10^4 and
10^5 CFU/ml are considered doubtful and should be clinically correlated.
Identification:
The colonies grown are identified, either using automated identification systems
like MALDI-TOF or VITEK or through conventional biochemical tests.
Antibody-coated bacteria test
In Upper UTI as spread via blood the bacteria are coated with antibodies which
can be detected by fluorescence techniques.
In Lower UTI no such finding is present.
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213 SEHRA
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:
Sexually transmitted: Caused by Treponema pallidum, leading to syphilis.
Nonvenereal treponematosis: Caused by T. pertenue, T. endemicum, and

T. carateum. These are similar to T. pallidum but transmitted by non-sexual
contact and produce nongenital cutaneous manifestations.
Syphilis passes through four stages if left untreated. Congenital syphilis can affect
newborns.
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).
Secondary Syphilis:
Develops 6–12 weeks after primary lesion healing.

Characterized by skin rashes, condylomata lata, mucous patches, and generalized

lymphadenopathy.
Latent Syphilis:
Follows secondary syphilis.

Absence of clinical manifestations but positive serological tests for syphilis.

Late or Tertiary Syphilis:
Develops several decades after the initial infection.

Gumma (granulomatous lesions), neurosyphilis, and cardiovascular syphilis are

manifestations.
Direct Microscopy (Demonstration of Treponemes):
Dark Ground Microscopy (DGM) is used to visualize Treponema pallidum.

Treponemes appear as slender, flexible, spirally coiled bacilli with corkscrew

motility.
Direct Fluorescent Antibody Staining for T. pallidum (DFa-Tp):
Smears from exudates or tissue sections are stained with fluorescent-labeled

monoclonal antibodies.
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T. pallidum appears as apple-green fluorescent-colored bacilli.

Silver Impregnation Staining:
Used to increase Treponema thickness for easier visualization.

SEROLOGY (ANTIBODY DETECTION)
Non-Treponemal Tests:
These tests detect non-specific antibodies called reagin antibodies in the patient’s
serum.
Reagin antibodies react with cardiolipin antigen derived from bovine heart.
Reagin antibodies are typically IgG, sometimes IgM, and are distinct from IgE class
reagin antibodies found in type I hypersensitivity reactions.
Examples of non-treponemal tests include VDRL, RPR, USR, and TRUST.
VDRL (Venereal Disease Research Laboratory):

It’s a precipitation (slide flocculation) test.
A positive test (reactive) is indicated by the formation of medium to large clumps
of antigen-antibody complexes.
CSF antibodies: VDRL can be used to detect antibodies in cerebrospinal fluid (CSF).
Utility: VDRL is cost-effective and often used as a screening test, for batch testing
(e.g., antenatal screening), and to monitor treatment response.
Rapid Plasma Reagin (RPR):
A slide flocculation test using disposable plastic cards with clearly defined circles,
similar to VDRL
Used for detecting antibodies in blood, not CSF.
Advantages of Non-Treponemal Tests:

Recommended for monitoring treatment response.
VDRL can detect CSF antibodies for neurosyphilis.
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:
TPI (T. pallidum Immobilization Test):
Uses live, actively motile T. pallidum (Nichols strain).

T. pallidum becomes immobilized when it combines with specific antibodies in

the patient’s serum.
FTA-ABS (Fluorescent Treponemal Antibody Absorption Test):
The patient’s serum is layered on a slide previously coated with killed T. pallidum.

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

examined under a fluorescent microscope.
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:
PCR-based techniques
Genital
Features Syphilis Chancroid LGV Donovanosis
Herpes
Incubation 9-90 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, multiple, 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
adenopathy
indurated bilateral swelling unilateral may be
(firm), with initial leads 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)
Differential Diagnosis Laboratory Tests Gram Stain Findings
Herpes Simplex Virus Viral culture, PCR, Tzanck smear:

(HSV) serology (IgG/IgM) Multinucleated giant cells
with intranuclear inclusions
(Cowdry Type A)
Syphilis Serological tests (VDRL, Dark-field microscopy:
RPR, TPPA, FTA-ABS) Spirochetes (Treponema
pallidum)
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Chancroid Culture of Haemophilus Gram-negative coccobacilli

ducreyi
Lymphogranuloma PCR for Chlamydia Intracytoplasmic inclusions

venereum (LGV) trachomatis (reticulate bodies)
Granuloma Inguinale PCR, culture, tissue Donovan bodies
(Donovanosis) biopsy
Life cycle of chlamydia
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217 SEHRA
89. A 42 year old female presents to the OPD with curdy white discharge from the
vagina. Her RBS came out to be 440 mg/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 external genitalia (vulva). It’s a common 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
Trichomoniasis
Bacterial vaginosis
Vaginal candidiasis.
Trichomoniasis is the most common parasitic sexually transmitted infection (STI)

caused by the flagellated parasite Trichomonas vaginalis.
Life Cycle:
Acquired through sexual contact.
Flagellated trophozoites enter the body, transform into amoeboid forms, multiply
in the genital tract, and cause infection.
They can revert to flagellated trophozoites, which are discharged in vaginal or
urethral secretions.
Clinical Features:
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).
Chronic infection: Milder symptoms like pruritus, pain during coitus, scanty vaginal
discharge mixed with mucus.
Direct Microscopy:
Examine vaginal, urethral discharge, urine sediment, or prostatic secretions.

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.
Culture: Process specimens into media like Lash’s cysteine hydrolysate serum media.
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Antigen Detection: Rapid ICT and ELISA using monoclonal antibodies in vaginal
secretion.
Antibody Detection: ELISA to detect antibodies in secretion.
Molecular Methods: PCR targeting specific T. vaginalis genes (e.g., beta-tubulin

gene).
Supportive Tests:
Raised vaginal pH (>4.5).
Positive whiff test: Accentuated fishy odor with 10% KOH in vaginal discharge
(positive in trichomoniasis and bacterial vaginosis).
Increased pus cells on wet mount.
Trophozoite Characteristics:
Pear-shaped.
Jerky/twitching motility in saline mount.
Five flagella (four anterior, one lateral - recurrent flagellum).
Single nucleus with central karyosome and evenly distributed nuclear chromatin.
Cytoplasm contains siderophore granules along the axostyle.
Bacterial vaginosis
It is not and infection just the mere proliferation of bacteria in the vagina.
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Gardenella vaginalis (m/c)
Mycoplasma hominis
There are some of the common causes of bacterial vaginosis.

Amsel’s Criteria (Clinical Diagnosis):
Bacterial vaginosis is often clinically diagnosed using Amsel’s criteria.
Diagnosis is made if any 3 of the following 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 10%
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):
Nugent’s score is a scoring system used for diagnosing bacterial vaginosis.
Culture:
Gardnerella vaginalis requires enriched media such as chocolate agar or BHI broth
with serum.
It appears gram-variable in smears and forms small pleomorphic rods with
metachromatic granules.
Hemolytic colonies can be observed on blood agar when incubated aerobically.
Vulvovaginal Trichomonal
Feature Bacterial Vaginosis
Candidiasis Vaginitis
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 Usually >4.5

Fishy odor with None May be present Present
10% KOH
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Vaginal May be present Colpitis macularis None

inflammation (strawberry
(erythema) appearance)
Microscopy of Leukocytes, Leukocytes; Clue cells, few
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
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221 SEHRA
90. Explain gonococcal and nongonococcal urethritis. (10 marks)
Answer
Gonococcal urethritis is a sexually transmitted infection caused by Neisseria
gonorrhoeae, a nonencapsulated, gram-negative, kidney-shaped diplococcus.
Virulence factors
Pili or fimbriae: These are the primary virulence factors of gonococci. They facilitate
adhesion to host cells and protect bacteria from phagocytosis.
Outer membrane proteins: Porin (protein I) forms transmembrane channels that
aid in molecule exchange across the gonococcal surface.
Opacity-associated protein (Protein II): This protein assists in adhesion to neutrophils
and other gonococci.
Clinical manifestations of gonorrhea vary between males and females:

In Males:
Acute urethritis is the most common presentation, characterized by purulent
urethral discharge.
Untreated cases may lead to complications such as epididymitis, prostatitis, and
balanitis.
Infections can spread to periurethral tissues, leading to abscess formation known
as water can perineum.
In Females:
Mucopurulent cervicitis is a common presentation with scanty vaginal discharge.
Vulvovaginitis: can occur in prepubertal girls and postmenopausal women with

different vaginal characteristics.
Fitz-Hugh-Curtis syndrome: complicated form of infection characterized by
peritonitis and perihepatic inflammation.
In pregnant women, it may cause complications such as premature delivery,
chorioamnionitis, and sepsis in infants.
In neonates, ophthalmia neonatorum presents with purulent eye discharge and
occurs within days of birth, transmitted during delivery.
Preferred specimens for diagnosing gonorrhea are urethral swabs in men and
cervical swabs in women. Vaginal swabs are not as reliable.
Dacron or rayon swabs are preferred, as cotton and alginate swabs can inhibit
gonococci.
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Transport Media:
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:
Gram staining of urethral exudates can reveal gram-negative intracellular kidney-
shaped diplococci.
Gram staining is highly specific and sensitive in symptomatic men but less so in
women due to the presence of commensal Neisseria species.
Culture:
Selective media, such as Thayer Martin medium, are used for culturing because
cervical swabs contain normal flora.
Identification 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:
Nucleic acid amplification tests (NAATs) like PCR are available that target specific
genes like 16s or 23s rRNA for accurate diagnosis.
Non-Gonococcal Urethritis (NGU):
Chronic urethritis without the presence of gonococci is termed non-gonococcal
urethritis (NGU). NGU is more prevalent than gonococcal urethritis.
Bacteria
Chlamydia trachomatis: This is the most common causative agent of NGU.

Urogenital Mycoplasma: Ureaplasma urealyticum and Mycoplasma hominis.

Viruses: Herpes simplex virus
Fungi: Candida albicans
Parasites: Trichomonas vaginalis
Nongonococcal Urethritis
Characteristic Gonococcal Urethritis
(NGU)
Causative Agent Neisseria gonorrhoeae, Various bacteria, including
a bacterium causing Chlamydia trachomatis,
gonorrhea. Mycoplasma genitalium,
and Ureaplasma
urealyticum, among
others.
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Common Symptoms Dysuria (painful Dysuria (painful

urination) - Urethral urination)
discharge (often
Urethral discharge (clear
yellow or green)
or cloudy)
Frequent urination
Frequency and urgency of
Genital discomfort urination
Genital discomfort
Microscopic Examination Gram-negative No characteristic
intracellular diplococci microorganisms visible
(GNID) often visible in under the microscope in
urethral discharge. NGU.
Diagnosis Identification of Detection of non-

Neisseria gonorrhoeae gonococcal pathogens like
via culture or nucleic Chlamydia trachomatis
acid amplification using NAATs.
tests (NAATs).
No characteristic findings
Gram staining may on Gram stain.
reveal GNID.
Treatment Antibiotics effective Antibiotics that cover
against Neisseria a broad spectrum of
gonorrhoeae, such bacteria, often including
as ceftriaxone and azithromycin or
azithromycin. doxycycline.
Complications If left untreated, Untreated NGU can lead

gonococcal infection to complications such
can lead to severe as epididymitis in men
complications, and pelvic inflammatory
including pelvic disease (PID) in women,
inflammatory disease which may result in
(PID), infertility, infertility.
and disseminated
gonococcal infection
(DGI).

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Miscellaneous
91. What are oncogenic viruses? Explain in brief about the mechanism of oncogenesis
in EBV and HPV infection. (3 marks)
Answer:
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:
EBV: leads to Burkitt lymphoma, nasopharyngeal carcinoma, Hodgkin’s lymphoma
etc
HPV: leads to cervical cancer, laryngeal carcinoma etc
Hepatitis B: causes hepatocellular carcinoma
HTLV1: causes adult T cell leukaemia.
HPV
Types 1, 2, 4, and 7 are associated with benign squamous papillomas or warts.
HPV subtypes 16, 18, 31, 33, 35, and 51 are linked to the development of
squamous cell carcinomas (SCCs) in the cervix, and anogenital region, as well as
oral and laryngeal cancers.
HPV 6 and 11 are responsible for causing genital lesions with low malignant
potential.
Mechanism: High-risk strains of HPV Produce E6 and E7 proteins. E6 inhibits the
p53 protein and E7 inhibits the RB protein causing uncontrolled cell proliferation.
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Ebstein barr virus (EBV)

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Miscellaneous
92. Write in brief about the plague. (3 marks)
Answer:
Bubonic Plague Pneumonic Plague Septicemic Plague
Transmission Bite of infected Inhalation 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 regional 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 Sudden onset Sudden fever Massive skin
fever, malaise, and mucosal
Headache
headache hemorrhages
Respiratory
Painful Gangrene of
symptoms
lymphadenitis affected areas
(cough,
(swollen, tender (historically
hemoptysis,
lymph nodes referred to as the
dyspnea, chest
known as “black death”)
pain)
buboes, often
in the inguinal Highly
area) infectious and
highly fatal
Potential
dissemination Bioterrorism
leading to risk, especially
secondary in non-endemic
pneumonia and regions
meningitis
Bubonic Plague: Pus or fluid from buboes.

Pneumonic Plague: Sputum and blood.

Septicemic Plague: Blood and splenic aspirate.

Direct Microscopy:
Stains like Gram stain and Wayson stain reveal bipolar or safety pin appearance

of Y. pestis.
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Culture:
Y. pestis grows on blood agar (dark-brown pigmented colonies) and MacConkey

agar (non-lactose fermenting colonies).
Biochemical Tests:
Catalase Positive, Oxidase Negative.

ICUT Tests: I-, C-, U-.

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

MALDI-TOF:
Automated identification system.

F1 Antigen Detection:
Direct Immunofluorescence Test.

ELISA.

Immunochromatographic Test (ICT).

Antibodies to F1 Antigen Detection:
ELISA or passive agglutination tests.

Molecular Methods:
PCR for targeting Y. pestis genes (F1 antigen, pesticin, plasminogen activator).

Treatment:
Gentamicin (DOC).

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Miscellaneous
93. Write in brief about tularaemia. (3 marks)
Answer:
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 typically acquired through:
Interaction with biting or blood-sucking insects, especially ticks and tabanid flies.

Ingestion of contaminated water or food.

Inhalation of infective aerosols.

Ulceroglandular tularemia: This is the most common form. It is characterized by
ulcerative lesions at the site of infection, accompanied by swollen regional lymph
nodes.
Other forms include pulmonary, oropharyngeal, oculoglandular, and typhoid-like
illnesses.
Tularemia can lead to complications such as suppurated lymph nodes, acute kidney
injury, hepatitis, rhabdomyolysis, empyema, pericarditis, meningitis, osteomyelitis,
and endocarditis.
Due to its high infectiousness, F. tularensis is classified as a category A agent of
bioterrorism.
Specimen collection
Preferred specimens for testing include ulcer scrapings and lymph node biopsies.
Strict biosafety precautions, such as biosafety level III, must be followed when
handling clinical specimens to prevent laboratory-acquired infections.
Culture
F. tularensis is highly fastidious
Special media like BCG agar (blood cysteine glucose agar) are required for isolation.
Species identification
Conventional biochemical tests or automated identification systems like VITEK.
Antibody detection
Agglutination tests (latex and tube agglutination) and ELISA formats are available.
Molecular tests
PCR assays
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94. Enumerate emerging and re-emerging infections. (3 marks)
Answer:
Emerging Infections
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 Parvovirus B-19
Plasmodium knowlesi (a malaria parasite)
MERS-CoV (Middle East Respiratory Syndrome Coronavirus)
SFTS virus (Severe Fever with Thrombocytopenia Syndrome

virus)
Nipah virus
SARS-CoV-2 (responsible for COVID-19)
Re-emerging Infections
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 Vibrio cholerae O139 (causing cholera)
Plague
Diphtheria
Chandipur virus
Chikungunya virus
Edition, Page No. Annexure 3
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ASHISH230SEHRA
Miscellaneous
95. What are vector-borne diseases? Enumerate with examples. (3 marks)
Answer:
Vector-borne infections are diseases that are spread by vectors.
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
Edition, Page No. annexure 7
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231 SEHRA
96. Explain the brief about the common congenital infection. (5 marks)
Answer:
Laboratory
Clinical Features Transmission
Diagnosis
Congenital Often asymptomatic Serological tests Highest risk
Toxoplasmosis in infants but can for antibodies is in the third
cause: (IgM and IgG) trimester
Jaundice PCR for
Seizures Toxoplasma
gondii DNA
Anemia
Imaging
Enlarged liver/
(ultrasound
spleen
or MRI) to
Ocular abnormalities detect brain
Hearing loss abnormalities
Neurological
complications
Congenital May lead to: Serological Highest risk
Rubella Classic triad (heart testing to is during the
defects, deafness, detect rubella- first trimester
eye abnormalities) specific IgM but can occur
antibodies in throughout
Low birth weight,
neonatal blood pregnancy
growth retardation
Viral culture or
Neurological
PCR from blood
abnormalities
or throat swabs
Congenital CMV Symptoms can include: PCR or viral Can occur at
Infection Microcephaly culture from any time during
urine, saliva, or pregnancy
Seizures
blood
Petechiae
Detection of
Hepatosplen- CMV-specific
omegaly IgM antibodies
Sensorineural
hearing loss
Chorioretinitis
and optic nerve
abnormalities
Neurological
complications
ASHISH232SEHRA
Miscellaneous
Congenital Early symptoms may Serological tests During any

Syphilis include: for syphilis stage of
Skin rashes (VDRL and pregnancy when
(condyloma lata) FTA-ABS) the mother is
infected with
Hepatosplenomegaly Dark-field
syphilis
microscopy of
Bone abnormalities
lesions
(saber shins)
PCR for
Late-stage
Treponema
complications can pallidum DNA
affect multiple
organs
Congenital HIV Early symptoms are Detection of During
Infection often non-specific HIV-specific pregnancy,
Chronic diarrhea, antibodies (IgG childbirth, or
oral thrush and IgM) in breastfeeding
Neurological neonatal blood when the
complications mother is HIV-
PCR for HIV
(encephalopathy, positive
RNA
seizures)
Lymphadenopathy
and
hepatosplenomegaly
may be present
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97. Write in brief about the parasite schistosoma haematobium. (3 marks)
Answer:
LIFE CYCLE
Involves three forms: adult worms, eggs, and larvae. This parasite has a two-
host life cycle, with humans as the definitive host and freshwater snails as the
intermediate host.
Cercariae penetrate the skin, travel through dermal veins, enter the bloodstream,
and eventually reach the portal system.
In the portal system, they develop into adult worms.
Adult worms migrate to the vesical and ureteric venous plexuses, where fertilization
occurs, leading to the production of eggs excreted in urine.
The pre-patent period for the human cycle is about 3 months, during which eggs
appear in the urine.
Pathogenesis and clinical features

Acute Schistosomiasis: Initial invasion of cercariae causes dermatitis at penetration
sites, leading to pruritic papular lesions.
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Miscellaneous
Chronic Schistosomiasis:
Urogenital disease: Eggs deposited in the bladder mucosa lead to dysuria and

hematuria. Egg antigens cause delayed hypersensitivity reactions and granuloma
formation.
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.
Urine Microscopy:
Detecting terminal spined eggs in urine characterized by elliptical shape with a
sharp terminal spine.
Histopathology: Demonstrating eggs in bladder mucosal biopsy or wet cervical
biopsy specimens in females.
Antibody Detection: Tests for detecting serum antibodies against S. haematobium
adult worm microsomal antigen (HAMA).
Antigen Detection: Detecting circulating antigen CCA and CAA in serum and
urine, indicating recent infection and treatment response.
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98. Write in brief about Enterobius vermicularis. (3 marks)
Answer:
Life cycle:
Transmission: Infection occurs through:
Autoinfection

Ingestion of Eggs

Development in Man: The eggs typically contain fully developed larvae.
After hatching in the cecum, larvae develop into adult worms.

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 10,000 eggs per day.

These eggs are embryonated and infective to humans, continuing the life cycle.

Pathogenicity and Clinical Features:
Cardinal symptoms include perianal pruritus (itching around the anus), especially
at night due to the nocturnal migration of female worms.
Worms may be found in undergarments or buttock area.
Scratching can lead to contaminated fingers and autoinfection.
Abdominal pain and weight loss may occur in heavy infections.
Other sites involved can include the urinary tract, peritoneal cavity, lungs, and
liver.
Eosinophilia
Microscopy of perianal skin samples is the preferred method to detect characteristic
eggs.
Two collection methods are commonly used: cellophane tape and the NIH swab.
Stool examination is generally not effective 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.

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Miscellaneous
99. Write in brief about trypanosomiasis. (3 marks)
Answer:
African Trypanosomes (Trypanosoma brucei complex): Transmitted by tsetse flies,
they cause African sleeping sickness.
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 → Amastigotes in tissues →
Multiply → Back to Trypomastigotes → Found
in blood.
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’ Disease 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
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237 SEHRA
100. Write in brief about scabies disease. (3 marks)
Answer:
Scabies, caused by the itch mite Sarcoptes scabiei, is transmitted through contact
with infested individuals or indirectly via shared items like clothing and bedding,
particularly in crowded conditions.
Initial Infestation: asymptomatic for two months, during which transmission can
occur. In cases of reinfection, symptoms appear much sooner, typically within 1-4
days.
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.
Crusted (Norwegian) Scabies: This severe form occurs in immunocompromised
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 itching.
Secondary Bacterial Infections can occur
The laboratory diagnosis of scabies involves confirming clinical suspicions by isolating
mites or their eggs through skin scrapings, particularly in the finger webs and
wrist folds.
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.
Identification: Sarcoptes scabiei mites are very small and just visible to the naked
eye.
Treatment:
The treatment of choice is permethrin 5% cream.

ASHISH238SEHRA
Miscellaneous
ASHISH
239 SEHRA

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Contents

Feature Endotoxins Exotoxins

Source Part of the cell wall Secreted by bacteria

Heat stability Highly stable Mostly enzyme-like action

Mode of action IL-I and TNF-alpha Specific action on particular

2. What is the difference between Gram-positive and Gram-negative bacterial cell

Characters Gram-positive cell wall Gram-negative cell wall

At the 3rd position of the L-Lysine present Mesodiaminopimelic acid

Lipid content Very less ~ 2% Around 15%

Lipopolysaccharide Absent Present as endotoxin

Teichoic acid Present Absent

Aromatic amino acids Absent Present

3. (A) What is the Koch postulate? (5 Marks)

(B) Explain bacterial growth curve?

It should be possible

Exceptions to Koch postulate

Moisture and desiccation

Mechanical and sonic stresses.

Antibiotic resistance means the property of a bacteria to resist the effect of

Mechanisms of antibiotic resistance are:

Reduced Cell-wall Pseudomonas, Enterobacter, Imipenem,

Efflux Pumps Escherichia coli, Tetracyclines,

Staphylococci Macrolides, Streptogramins

Staphylococcus aureus, Fluoroquinolones

Enzymatic β-lactamase-producing β-lactam antibiotics

M. tuberculosis Ribosomal proteins, 16S

Antimicrobial susceptibility testing-

Method Description Applicability

Dilution Testing Serial dilution of MIC is the lowest

Epsilometer (E-test) Quantitative method using Determines MIC using

Mutational drug resistance Transferable drug resistance

Resistance to one drug at a time Multiple drug resistance at the same

Resistance can be overcome by a Cannot be overcome by drug

5. Write the laboratory diagnosis of fungal infection in brief. (5 Marks)

Detect fungal antigens (e.g., beta-D-glucan) in clinical samples.

Utilize immunohistochemistry to detect antigens on cells in tissue sections.

Automated Identification Systems

6. Write a brief account of the mechanism of gene transfer in bacteria.

Horizontal gene transfer

One strand is degraded by the exonucleases of the recipient cell

The other strand is internalized by binding to competency-specific

Life cycle Description

Lytic or Virulence Cycle Bacteriophages multiply inside the host

Lysogenic or Temperate Cycle The host bacterium remains unharmed.

Phage’s DNA integrates into bacterial DNA.

Types of Gene Transfer

Besides chromosomal DNA, transduction is also a method of introducing episomes

Treatment: Transduction has also been proposed as a genetic engineering approach

Lysogenic phage DNA can contribute to bacterial virulence by encoding the

For example, in Corynebacterium diphtheriae, the diphtheria toxin is encoded

Bacterial toxins encoded by lysogenic phages include:

Streptococcus pyrogenic exotoxin (SPE-A and C)

Conjugation is the process of transferring genetic material from one bacterium

The F factor is a conjugative plasmid.

During conjugation, plasmid DMA replicates through a rolling circle mechanism

Then, in the recipient, the incoming strand is copied to produce a full-length

During F+ X F-binding, the chromosomal gene of the donor bacterium is

This whole process is known as sexduction.

Clinical Assessment- Begin with patient evaluation, considering symptoms and

(B) Explain bacterial growth curve?

It should be possible

Moisture and desiccation

Mechanical and sonic stresses.

Antibiotic resistance means the property of a bacteria to resist the effect of

Dilution Testing Serial dilution of MIC is the lowest

Epsilometer (E-test) Quantitative method using Determines MIC using

Resistance to one drug at a time Multiple drug resistance at the same

Resistance can be overcome by a Cannot be overcome by drug

Detect fungal antigens (e.g., beta-D-glucan) in clinical samples.

Utilize immunohistochemistry to detect antigens on cells in tissue sections.

Automated Identification Systems

Lysogenic or Temperate Cycle The host bacterium remains unharmed.

Phage’s DNA integrates into bacterial DNA.

Treatment: Transduction has also been proposed as a genetic engineering approach

Bacterial toxins encoded by lysogenic phages include:

Conjugation is the process of transferring genetic material from one bacterium

Virus Detection from Tissue Culture.

Immunoelectron Microscopy: Enhanced with specific antiviral antibodies.

Direct Immunofluorescence (Direct-IF): Detects viral particles in clinical samples.

Light Microscopy: Useful for inclusion bodies and immunoperoxidase staining.

Techniques like ELISA, ELFA, and ICT are commonly used.

PCR for viral DNA (e.g., HSV DNA in CSF).

RT-PCR for RNA viruses (e.g., HIV RNA in blood).

Real-time PCR (rt-PCR) for various viral infections.

Used for research purposes and diagnosing hard-to-cultivate viruses.

Immune response against first antigen Immune response against subsequent

The lag period is longer The lag period is absent or short

No negative phase A negative phase may occur

Antibody-producing cells- Naive B Antibody-producing cells- Memory B

Produced actively by the host immune Immunoglobulins received passively

Lag period present No Lag period

Memory present No memory

Not useful in immunodeficient Useful in immunodeficient individuals

Hypervariable regions, which represent the antigen-binding sites of antibodies:

IgG IgG1, IgG2, IgG3, Crosses placenta

Mediates precipitation and

Easily recognized and removed once

Secretory IgA rich in breast milk

Steps of Complement Activation:

Vasoconstriction (narrowing of blood vessels).

Meaning It is associated with the It is associated with the

Mediated by B-lymphocytes These are associated with

Function It plays a major role in Cell-mediated immunity is

Secretes It secret antibodies. It secretes cytokines

Hypersensitivity It involved in type I, II, III Type IV

Rejections Humoral immunity is Cell-mediated immunity is

Infection with M.Tb Initial contact with Mycobacterium

Entry into Macrophages Phagocytosis of M.Tb by macrophages

Replication in Macrophages Inhibition of phagosome maturation and

Initial Innate Immune Response Recognition by TLR2 and TLR9, initiating

Th1 Response Th1 cell activation is triggered by antigen

Th1-Mediated Macrophage Activation IFN-γ production, phagolysosome