SELF-ASSESSMENT QUESTIONS

1. You’re watching a television program that is discussing viruses called

bacteriophages that can kill bacteria. Your roommate says, “Wow, maybe viruses

can be used to kill the bacteria that infect people! You’re taking the Microbiology

course now; what’s the difference between viruses and bacteria?” Which one of

the following would be the most accurate statement to make?

(A) Viruses do not have mitochondria, whereas bacteria do.

(B) Viruses do not have a nucleolus, whereas bacteria do.

(C) Viruses do not have ribosomes, whereas bacteria do.

(D) Viruses replicate by binary fission, whereas bacteria replicate by mitosis.

(E) Viruses are prokaryotic, whereas bacteria are eukaryotic.

2. Bacteria, fungi (yeasts and molds), viruses, and protozoa are important causes of

human disease. Which one of the following microbes contains either DNA or

RNA but not both?

(A) Bacteria

(B) Molds

(C) Protozoa

(D) Viruses

(E) Yeasts

3. Which one of the following contains DNA that is not surrounded by a nuclear

membrane?

(A) Bacteria

(B) Molds

(C) Protozoa

(D) Yeasts

SELF-ASSESSMENT QUESTIONS

1. The initial step in the process of many bacterial infections is adherence of the
organism to mucous membranes. The bacterial component that mediates

adherence is the:

(A) Lipid A

(B) Nucleoid

(C) Peptidoglycan

(D) Pilus

(E) Plasmid

2. In the Gram stain procedure, bacteria are exposed to 95% alcohol or to anacetone/alcohol
mixture. The purpose of this step is:

(A) To adhere the cells to the slide

(B) To retain the purple dye within all the bacteria

(C) To disrupt the outer cell membrane so the purple dye can leave the bacteria

(D) To facilitate the entry of the purple dye into the gram-negative cells

(E) To form a complex with the iodine solution

3. In the process of studying how bacteria cause disease, it was found that a rare

mutant of a pathogenic strain failed to form a capsule. Which one of the following

statements is the most accurate in regard to this unencapsulated mutant strain?

(A) It was nonpathogenic primarily because it was easily phagocytized.

(B) It was nonpathogenic primarily because it could not invade tissue.

(C) It was nonpathogenic primarily because it could only grow anaerobically.

(D) It was highly pathogenic because it could secrete larger amounts of exotoxin.

(E) It was highly pathogenic because it could secrete larger amounts of

endotoxin.

4. Mycobacterium tuberculosis stains well with the acid-fast stain, but not with the

Gram stain. Which one of the following is the most likely reason for this

observation?

(A) It has a large number of pili that absorb the purple dye.

(B) It has a large amount of lipid that prevents entry of the purple dye.
(C) It has a very thin cell wall that does not retain the purple dye.

(D) It is too thin to be seen in the Gram stain.

(E) It has histones that are highly negatively charged.

5. Of the following bacterial components, which one exhibits the most antigenic

variation?

(A) Capsule

(B) Lipid A of endotoxin

(C) Peptidoglycan

(D) Ribosome

(E) Spore

6. β-Lactamases are an important cause of antibiotic resistance. Which one of the

following is the most common site where β-lactamases are located?

(A) Attached to DNA in the nucleoid

(B) Attached to pili on the bacterial surface

(C) Free in the cytoplasm

(D) Within the capsule

(E) Within the periplasmic space

7. Which one of the following is the most accurate description of the structural

differences between gram-positive bacteria and gram-negative bacteria?

(A) Gram-positive bacteria have a thick peptidoglycan layer, whereas gram negative

bacteria have a thin layer.

(B) Gram-positive bacteria have an outer lipid-rich membrane, whereas gram negative

bacteria do not.

(C) Gram-positive bacteria form a sex pilus that mediates conjugation, whereas

gram-negative bacteria do not.

(D) Gram-positive bacteria have plasmids, whereas gram-negative bacteria do

not.
(E) Gram-positive bacteria have capsules, whereas gram-negative bacteria do

not.

8. Bacteria that cause nosocomial (hospital-acquired) infections often produce

extracellular substances that allow them to stick firmly to medical devices, such

as intravenous catheters. Which one of the following is the name of this

extracellular substance?

(A) Axial filament

(B) Endotoxin

(C) Flagella

(D) Glycocalyx

(E) Porin

9. Lysozyme in tears is an effective mechanism for preventing bacterial

conjunctivitis. Which one of the following bacterial structures does lysozyme

degrade?

(A) Endotoxin

(B) Nucleoid DNA

(C) Peptidoglycan

(D) Pilus

(E) Plasmid DNA

10. Several bacteria that form spores are important human pathogens. Which one of

the following is the most accurate statement about bacterial spores?

(A) They are killed by boiling for 15 minutes.

(B) They are produced primarily by gram-negative cocci.

(C) They are formed primarily when the bacterium is exposed to antibiotics.

(D) They are produced by anaerobes only in the presence of oxygen.

(E) They are metabolically inactive yet can survive for years in that inactive

state.
1. Figure 3–1 depicts a bacterial growth curve divided into phases a, b, c, and d. In

which one of the phases are antibiotics such as penicillin most likely to kill

bacteria?

(A) Phase a

(B) Phase b (log phase)

(C) Phase c

(D) Phase d

2. Some bacteria are obligate anaerobes. Which of the following statements best

explains this phenomenon?

(A) They can produce energy both by fermentation (i.e., glycolysis) and by

respiration using the Krebs cycle and cytochromes.

(B) They cannot produce their own ATP.

(C) They do not form spores.

(D) They lack superoxide dismutase and catalase.

(E) They do not have a capsule.

1. The emergence of antibiotic-resistant bacteria, especially in enteric gram negative

rods, is a medically important phenomenon. This most commonly occurs

by a process that involves a sex pilus and the subsequent transfer of plasmids

carrying one or more transposons. Which one of the following is the name that

best describes this process?

(A) Conjugation

(B) Transduction

(C) Transformation

(D) Translocation

(E) Transposition

2. Several important pathogenic bacteria have the ability to translocate pieces of

their DNA in a process called programmed rearrangements. Which one of the

following is the most important known consequence of this ability?

(A) The number of plasmids increases significantly, which greatly enhances

antibiotic resistance.

(B) The amount of endotoxin increases significantly, which greatly enhances the

ability to cause septic shock.

(C) The surface antigens of the bacteria vary significantly, which greatly

enhances the ability to avoid opsonization by antibody.

(D) The ability of the bacterium to be lysogenized is significantly increased,

which greatly enhances the ability to produce increased amounts of exotoxins.

(E) The ability of the bacterium to survive intracellularly is greatly increased.

3. Which statement is the most accurate regarding transposons?

(A) They encode enzymes that degrade the ends of the bacterial chromosome.

(B) They are short sequences of DNA that often encode enzymes that mediate

antibiotic resistance.

(C) They are short sequences of RNA that silence specific regulatory genes.

(D) They are a family of transfer RNAs that enhance mutations at “hot spots” in

the bacterial genome.

4. Corynebacterium diphtheriae cuases the disease diphtheria by producing

diphtheria toxin. The gene encoding the toxin is integrated into bacterial genome

during lysogenic conversion. The toxin gene was acquired by which process?

63

(A) Conjugation

(B) Transduction

(C) Transformation

(D) Translocation

(E) Transposition

1. The colon is the site of the largest number of normal flora bacteria. Which one of
the following bacteria is found in the greatest number in the colon?

(A) Bacteroides fragilis

(B) Clostridium perfringens

(C) Enterococcus faecalis

(D) Escherichia coli

(E) Lactobacillus species

2. A 76–year–old woman with a prosthetic (artificial) hip comes to you

complaining of fever and pain in that joint. You are concerned about an infection

by S. epidermidis. Using your knowledge of normal flora, what is the most likely

source of this organism?

(A) Dental plaque

(B) Mouth

(C) Skin

(D) Stomach

(E) Vagina

3. Your patient is a 30-year-old woman with a previous history of rheumatic fever

who has had fever for the past 2 weeks. On examination, you find a new heart

murmur. You suspect endocarditis and do a blood culture, which grows a

viridans group streptococcus later identified as S. sanguinis. Using your

knowledge of normal flora, what is the most likely source of this organism?

(A) Duodenum

(B) Skin

(C) Throat

(D) Urethra

(E) Vagina

4. An outbreak of postsurgical wound infections caused by S. aureus has occurred

in the hospital. The infection control team was asked to determine whether the
organism could be carried by one of the operating room personnel. Using your

knowledge of normal flora, which one of the following body sites is the most

likely location for this organism?

(A) Colon

(B) Gingival crevice

(C) Mouth

(D) Nose

(E) Throat

1. Handwashing is an important means of interrupting the chain of transmission from

one person to another. Infection by which one of the following bacteria is most

likely to be interrupted by handwashing?

(A) Borrelia burgdorferi

(B) Legionella pneumophila

(C) Staphylococcus aureus

(D) Streptococcus agalactiae (group B streptococcus)

(E) Treponema pallidum

2. Vertical transmission is the transmission of organisms from mother to fetus or

newborn child. Infection by which one of the following bacteria is most likely to

be transmitted vertically?

(A) Chlamydia trachomatis

(B) Clostridium tetani

(C) Haemophilus influenzae

(D) Shigella dysenteriae

(E) Streptococcus pneumoniae

3. The cells involved with pyogenic inflammation are mainly neutrophils, whereas

the cells involved with granulomatous inflammation are mainly macrophages and

helper T cells. Infection by which one of the following bacteria is most likely to
elicit granulomatous inflammation?

(A) Escherichia coli

(B) Mycobacterium tuberculosis

(C) Neisseria gonorrhoeae

(D) Streptococcus pyogenes

(E) Staphylococcus aureus

4. Which one of the following sets of properties of exotoxins and endotoxins is

correctly matched?

(A) Exotoxins—polypeptides; endotoxins—lipopolysaccharide

(B) Exotoxins—weakly antigenic; endotoxins—highly antigenic

(C) Exotoxins—produced only by gram-negative bacteria; endotoxins—produced

only by gram-positive bacteria

(D) Exotoxins—weakly toxic per microgram; endotoxins—highly toxic per

microgram

(E) Exotoxins—toxoid vaccines are ineffective; endotoxins—toxoid vaccines are

effective

5. Which one of the following sets consists of bacteria both of which produce

exotoxins that increase cyclic AMP within human cells?

(A) Vibrio cholerae and Corynebacterium diphtheriae

(B) Clostridium perfringens and Streptococcus pyogenes

(C) Escherichia coli and Bordetella pertussis

(D) Corynebacterium diphtheriae and Staphylococcus aureus

(E) Bacillus anthracis and Staphylococcus epidermidis

6. Which one of the following sets of bacteria produces exotoxins that act by
ADPribosylation?

(A) Corynebacterium diphtheriae and Escherichia coli

(B) Clostridium perfringens and Staphylococcus aureus

(C) Clostridium tetani and Bacillus anthracis

(D) Enterococcus faecalis and Mycobacterium tuberculosis

(E) Escherichia coli and Streptococcus pyogenes

7. Which of the following bacteria produce an exotoxin that inhibits the release of

acetylcholine at the neuromuscular junction?

(A) Bacillus anthracis

(B) Bordetella pertussis

(C) Clostridium botulinum

(D) Corynebacterium diphtheriae

(E) Escherichia coli

8. A 25-year-old man with abdominal pain was diagnosed with acute appendicitis.

He then had a sudden rise in temperature to 39°C and a sudden fall in blood

pressure. Which one of the following is the most likely cause of the fever and

hypotension?

(A) An exotoxin that ADP-ribosylates elongation factor-2

(B) An exotoxin that stimulates production of large amounts of cyclic AMP

(C) An endotoxin that causes release of tumor necrosis factor

(D) An endotoxin that binds to class I MHC protein

(E) An exoenzyme that cleaves hyaluronic acid

9. Several biotech companies have sponsored clinical trials of a drug consisting of

monoclonal antibody to lipid A. Sepsis caused by which one of the following sets

of bacteria is most likely to be improved following administration of this

antibody?

(A) Bordetella pertussis and Clostridium perfringens

(B) Escherichia coli and Neisseria meningitidis

(C) Pseudomonas aeruginosa and Bacillus anthracis

(D) Staphylococcus epidermidis and Staphylococcus aureus

(E) Streptococcus pneumoniae and Staphylococcus aureus

10. Regarding endotoxin, which one of the following is the MOST accurate?

(A) Endotoxin is a polypeptide, the toxic portion of which consists of two Dalanines.

(B) Endotoxin is produced by both gram-positive cocci as well as gram-negative

cocci.

(C) Endotoxin acts by binding to class II MHC proteins and the variable portion

of the beta chain of the T-cell receptor.

(D) Endotoxin causes fever and hypotension by inducing the release of

interleukins such as interleukin-1 and tumor necrosis factor.

(E) The antigenicity of endotoxin resides in its fatty acid side chains.

ANSWERS

1. (C)

2. (A)

3. (B)

4. (A)

5. (C)

6. (A)

7. (C)

8. (C)

9. (B)

10. (D)

SELF-ASSESSMENT QUESTIONS

1. Which one of the following host defense processes is the MOST important in

preventing the action of exotoxins?

(A) Binding of cytokines to exotoxin-specific receptors inhibits the attachment of

exotoxins

141

(B) Degradation of exotoxins by the membrane attack complex of complement

(C) Lysis of exotoxins by perforins produced by cytotoxic T cells

(D) Neutralization of exotoxins by antibody prevents binding to target cell

membrane

(E) Phagocytosis of exotoxins by neutrophils and subsequent destruction by

hypochlorite

2. An inflammatory response in the skin is characterized by erythema (redness).

Which one of the following is the most important cause of this erythema?

(A) C3b component of complement

(B) Gamma interferon

(C) Histamine

(D) Hypochlorite

(E) Superoxide

3. A 1-year-old child with repeated infections was diagnosed with chronic

granulomatous disease (CGD). A defect in which one of the following is the

cause of CGD?

(A) Gamma interferon receptor

(B) LFA-integrins

(C) Mannose-binding protein

(D) NADPH oxidase

(E) Nitric oxide

4. Opsonization is the process by which:

(A) bacteria are made more easily phagocytized.

(B) chemokines attract neutrophils to the site of infection.

(C) neutrophils migrate from the blood through the endothelium to reach the site

of infection.

(D) the acute-phase response is induced.

(E) the alternate pathway of complement is activated.

ANSWERS

1. (D)

142

2. (C)

3. (D)

4. (A)

SELF-ASSESSMENT QUESTIONS

1. If the venipuncture site is inadequately disinfected, blood cultures are most often

contaminated with which one of the following bacteria?

(A) Escherichia coli

(B) Haemophilus influenzae

(C) Pseudomonas aeruginosa

(D) Staphylococcus epidermidis

(E) Streptococcus pneumoniae

2. The main purpose of performing a throat culture is to detect the presence of which

one of the following bacteria?

(A) Neisseria meningitidis

(B) Staphylococcus aureus

(C) Staphylococcus epidermidis

(D) Streptococcus pneumoniae

(E) Streptococcus pyogenes

3. A sputum culture will be rejected (i.e., it will not be stained or cultured) by the

clinical laboratory if:

(A) it is streaked with blood.

(B) it contains IgA antibody.

(C) it contains many more epithelial cells than neutrophils.

(D) it contains pus.

(E) it contains sulfur granules.

4. The identification of Salmonella and Shigella in stool cultures using Eosin–

Methylene Blue (EMB) media is dependent on which one of the following

properties?

(A) Salmonella and Shigella produce a blue colony in the presence of methylene

blue.

(B) Salmonella and Shigella produce a colorless colony because they do not

ferment lactose.

(C) Salmonella and Shigella produce a green colony because they utilize the bile

in the media.

(D) Salmonella and Shigella produce a red colony in the presence of eosin.

159

(E) Salmonella and Shigella produce a yellow colony because they ferment

glucose.

ANSWERS

1. (D)

2. (E)

3. (C)

4. (B)

SELF-ASSESSMENT QUESTIONS

1. Cefazolin is often given prior to surgery to prevent postsurgical wound infections.

Which one of the following best describes the mode of action of cefazolin?

(A) It acts as an electron sink depriving the bacteria of reducing power.

(B) It binds to the 30S ribosome and inhibits bacterial protein synthesis.

(C) It inhibits transcription of bacterial mRNA.

(D) It inhibits transpeptidases needed to synthesize peptidoglycan.

(E) It inhibits folic acid synthesis needed to act as a methyl donor.

2. Which one of the following drugs inhibits bacterial nucleic acid synthesis by

blocking the production of tetrahydrofolic acid?

(A) Ceftriaxone

(B) Erythromycin

(C) Metronidazole

(D) Rifampin

(E) Trimethoprim

3. Regarding both penicillins and aminoglycosides, which one of the following is

the most accurate?

(A) Both act at the level of the cell wall.

(B) Both are bactericidal drugs.

(C) Both require an intact β-lactam ring for their activity.

(D) Both should not be given to children under the age of 8 years because damage

to cartilage can occur.

(E) They should not be given together because they are antagonistic.

4. Listed below are drug combinations that are used to treat certain infections.

Which one of the following is a combination in which both drugs act to inhibit the

same metabolic pathway?

(A) Amphotericin and flucytosine

(B) Isoniazid and rifampin

(C) Penicillin G and gentamicin

(D) Sulfonamide and trimethoprim

5. Regarding penicillins and cephalosporins, which one of the following is the most

194

accurate?

(A) Cleavage of the β-lactam ring will inactivate penicillins but not

cephalosporins.
(B) Penicillins act by inhibiting transpeptidases but cephalosporins do not.

(C) Penicillins and cephalosporins are both bactericidal drugs.

(D) Penicillins and cephalosporins are active against gram-positive cocci but not

against gram-negative rods.

(E) Renal tubule damage is an important adverse effect caused by both penicillins

and cephalosporins.

6. Regarding antimicrobial drugs that act by inhibiting nucleic acid synthesis in

bacteria, which one of the following is the most accurate?

(A) Ciprofloxacin inhibits RNA polymerase by acting as a nucleic acid analogue.

(B) Rifampin inhibits the synthesis of messenger RNA.

(C) Sulfonamides inhibit DNA synthesis by chain termination of the elongating

strand.

(D) Trimethoprim inhibits DNA polymerase by preventing the unwinding of

double-stranded DNA.

7. Regarding aminoglycosides and tetracyclines, which one of the following is the

most accurate?

(A) Both classes of drugs are bactericidal.

(B) Both classes of drugs inhibit protein synthesis by binding to the 30S

ribosomal subunit.

(C) Both classes of drugs inhibit peptidyl transferase, the enzyme that synthesizes

the peptide bond.

(D) Both classes of drugs must be acetylated within human cells to form the

active antibacterial compound.

(E) Both classes of drugs cause brown staining of teeth when administered to

young children.

8. The selective toxicity of antifungal drugs, such as amphotericin B and

itraconazole, is based on the presence in fungi of which one of the following?

(A) 30S ribosomal subunit

(B) Dihydrofolate reductase

(C) DNA gyrase

195

(D) Ergosterol

(E) Mycolic acid

9. The next three questions ask about the adverse effects of antibiotics, which are an

important consideration when deciding which antibiotic to prescribe. Which

antibiotic causes significant neurotoxicity and must be taken in conjunction with

pyridoxine (vitamin B6) to prevent these neurologic complications?

(A) Amoxicillin

(B) Ceftriaxone

(C) Isoniazid

(D) Rifampin

(E) Vancomycin

10. Of the following antibiotics, which one causes the most phototoxicity (rash when

exposed to sunlight)?

(A) Amphotericin B

(B) Ciprofloxacin

(C) Gentamicin

(D) Metronidazole

(E) Sulfamethoxazole

11. Which of the following antibiotics causes “red man” syndrome?

(A) Azithromycin

(B) Doxycycline

(C) Gentamicin

(D) Sulfamethoxazole
(E) Vancomycin

ANSWERS

1. (D)

2. (E)

3. (B)

4. (D)

5. (C)

196

6. (B)

7. (B)

8. (D)

9. (C)

10. (E)

11. (E)

1. The spread of antibiotic resistance from one bacterium to another is a wellrecognized

and clinically important phenomenon. Which one of the following

mechanisms is most likely to be involved with the spread of resistance?

(A) Acetylation

(B) Conjugation

(C) Programmed rearrangement

(D) Protoplast mobility

(E) Translation

2. Regarding the specific mechanisms by which bacteria become resistant to

antimicrobial drugs, which one of the following is the most accurate?

(A) Some bacteria contain an enzyme that cleaves the ring of aminoglycosides.

(B) Some bacteria contain clavulanic acid, which binds to penicillin G and

inactivates it.
(C) Some bacteria contain a mutated gene encoding an altered transpeptidase,

which makes it resistant to doxycycline.

(D) Some bacteria contain a mutated gene that encodes an altered RNA

polymerase, which makes it resistant to rifampin.

(E) Some bacteria contain an altered ribosomal protein, which makes it resistant

to isoniazid.

3. The susceptibility of bacteria to an antibiotic is often determined by using the

minimal inhibitory concentration (MIC) assay. Regarding the MIC assay, which

one of the following is the most accurate?

(A) MIC is the lowest concentration of the bacteria isolated from the patient that

inhibits the activity of a standard dose of antibiotic.

(B) MIC is the lowest concentration of antibiotic that inhibits the growth of the

bacteria isolated from the patient.

(C) MIC is the lowest concentration of antibiotic that kills the bacteria isolated

from the patient.

(D) MIC is the lowest concentration of antibiotic in the patient’s serum that

inhibits the activity of a standard dose of antibiotic.

4. The minimal inhibitory concentration (MIC) of the patient’s organism to

penicillin is 1 μg/mL and the MIC to gentamicin is 8 μg/mL. However, the MIC

to a combination of penicillin and gentamicin is 0.01 μg/mL. Which one of the

following terms is the most accurate to describe this effect?

216

(A) Activation

(B) Antagonism

(C) Reassortment

(D) Recombination

(E) Synergism
5. Regarding the mechanisms of resistance to specific drugs, which one of the

following is most accurate?

(A) Certain strains of Enterococcus faecalis produce D-lactate rather than Dalanine,

which causes them to be resistant to vancomycin.

(B) Certain strains of Escherichia coli produce ergosterol, which causes them to

be resistant to gentamicin.

(C) Certain strains of Neisseria gonorrhoeae produce a mutant peptidyl

transferase, which causes them to be resistant to tetracycline.

(D) Certain strains of Streptococcus pyogenes produce a β-lactamase, which

causes them to be resistant to erythromycin.

ANSWERS

1. (B)

2. (D)

3. (B)

4. (E)

5. (A)

1. Which one of the following is the immunogen in the vaccine against

Streptococcus pneumoniae?

(A) Capsular polysaccharide

(B) Endotoxin

225

(C) Formaldehyde-killed organisms

(D) Pilus protein

(E) Toxoid

2. Disease caused by which one of the following bacteria is prevented by a toxoid

vaccine?

(A) Bacteroides fragilis

(B) Corynebacterium diphtheriae

(C) Neisseria meningitidis

(D) Salmonella typhi

(E) Vibrio cholerae

3. Disease caused by which one of the following bacteria is prevented by a vaccine

in which the immunogen is covalently bound to a carrier protein (conjugate

vaccine)?

(A) Bacillus anthracis

(B) Clostridium tetani

(C) Haemophilus influenzae

(D) Mycobacterium tuberculosis

(E) Streptococcus pyogenes

4. Passive immunity is used to prevent or to treat disease caused by which one of

the following sets of bacteria?

(A) Clostridium tetani and Clostridium botulinum

(B) Escherichia coli and Staphylococcus aureus

(C) Neisseria meningitidis and Bacillus anthracis

(D) Streptococcus pneumoniae and Haemophilus influenzae

(E) Streptococcus pyogenes and Salmonella typhi

ANSWERS

1. (A)

2. (B)

3. (C)

4. (A)

1. Regarding sterilization and disinfection, which one of the following is the most

accurate statement?

(A) Seventy percent alcohol is a better antiseptic than iodine, so 70% alcohol
should be used to disinfect the skin prior to drawing a blood culture rather

than iodine.

(B) Disinfectants kill both bacterial cells and bacterial spores.

(C) During sterilization by autoclaving, the temperature must be raised above

boiling in order to kill bacterial spores.

(D) Transmission of milk-borne diseases can be prevented by pasteurization,

which kills both bacterial cells and spores.

(E) Ultraviolet light used in the operating room to disinfect the room kills

bacteria primarily by causing oxidation of lipids in the cell membrane.

2. Which one of the following chemicals is used to sterilize heat-sensitive materials,

such as surgical instruments, in the hospital?

(A) Benzalkonium chloride

(B) Cresol (Lysol)

(C) Ethylene oxide

(D) Thimerosal

(E) Tincture of iodine

ANSWERS

1. (C)

2. (C)

1. The main reason why some bacteria are anaerobes (i.e., they cannot grow in the

presence of oxygen) is because:

(A) they do not have sufficient catalase and superoxide dismutase.

(B) they have too much ferrous ion that is oxidized to ferric ion in the presence of

oxygen.

(C) they have unusual mitochondria that cannot function in the presence of

oxygen.

(D) transcription of the gene for the pilus protein is repressed in the presence of
oxygen.

2. Which one of the following sets consists of bacteria that are both anaerobes?

(A) Actinomyces israeli and Serratia marcescens

(B) Campylobacter jejuni and Vibrio cholerae

(C) Clostridium perfringens and Bacteroides fragilis

(D) Mycobacterium tuberculosis and Pseudomonas aeruginosa

243

(E) Mycoplasma pneumoniae and Corynebacterium diphtheriae

ANSWERS

1. (A)

2. (C)

1. You’re in the clinical lab looking at a Gram stain when the laboratory technician

comes up to you and says, “I think your patient has Staph epi [short for

Staphylococcus epidermidis] bacteremia.” Which one of the following sets of

283

results did the tech find with the organism recovered from the blood culture?

(A) Gram-positive cocci in chains, catalase-positive, coagulase-positive

(B) Gram-positive cocci in chains, catalase-negative, coagulase-negative

(C) Gram-positive cocci in clusters, catalase-positive, coagulase-negative

(D) Gram-positive cocci in clusters, catalase-negative, coagulase-positive

(E) Gram-positive diplococci, catalase-negative, coagulase-positive

2. Superantigen production by Staphylococcus aureus is involved in the

pathogenesis of which one of the following diseases?

(A) Impetigo

(B) Osteomyelitis

(C) Scalded skin syndrome

(D) Septicemia
(E) Toxic shock syndrome

3. Which one of the following is the virulence factor produced by Staphylococcus

aureus that prevents the activation of complement and thereby reduces

opsonization by C3b?

(A) Catalase

(B) Coagulase

(C) Endotoxin

(D) Protein A

(E) Teichoic acid

4. The main reason why methicillin-resistant Staphylococcus aureus (MRSA)

strains are resistant to methicillin and nafcillin is:

(A) they produce β-lactamase that degrades the antibiotics.

(B) they have altered penicillin-binding proteins that have reduced binding of the

antibiotics.

(C) they have mutant porin proteins that prevent the antibiotics from entering the

bacteria.

(D) they have plasmid-encoded export proteins that remove the drug from the

bacteria.

5. A pore-forming exotoxin produced by Staphylococcus aureus that kills cells and

is important in the severe, rapidly spreading necrotizing lesions caused by MRSA

284

strains is:

(A) coagulase.

(B) enterotoxin.

(C) exfoliatin.

(D) P-V leukocidin.

(E) staphyloxanthin.
6. Of the following antibiotics, which one is the most appropriate to treat a severe

necrotizing skin infection caused by an MRSA strain of Staphylococcus aureus?

(A) Amoxicillin

(B) Ceftriaxone

(C) Ciprofloxacin

(D) Gentamicin

(E) Vancomycin

7. An outbreak of serious pneumococcal pneumonia and sepsis among inmates in an

overcrowded prison has occurred. Laboratory analysis determined that one

serotype was involved. The prison physician said that the pneumococcal vaccine

might have limited the outbreak. Which one of the following structures of the

pneumococcus is responsible for determining the serotype and is also the

immunogen in the vaccine?

(A) Capsule

(B) Flagellar protein

(C) O antigen

(D) Peptidoglycan

(E) Pilus protein

8. Which one of the following best describes the pathogenesis of rheumatic fever?

(A) An exotoxin produced by Streptococcus pyogenes that acts as a superantigen

damages cardiac muscle.

(B) An exotoxin produced by Streptococcus pyogenes that ADP-ribosylates a G

protein damages joint tissue.

(C) Antibody to the capsular polysaccharide of Streptococcus pyogenes crossreacts

with joint tissue and damages it.

(D) Antibody to the M protein of Streptococcus pyogenes cross-reacts with

285
cardiac muscle and damages it.

(E) Endotoxin produced by Streptococcus pyogenes activates macrophages to

release cytokines that damage cardiac muscle.

9. Which one of following laboratory tests is the most appropriate to distinguish

Streptococcus pyogenes from other β-hemolytic streptococci?

(A) Ability to grow in 6.5% NaCl

(B) Activation of C-reactive protein

(C) Hydrolysis of esculin in the presence of bile

(D) Inhibition by bacitracin

(E) Inhibition by optochin

10. Infections by which one of the following bacteria are typically treated with

penicillins such as amoxicillin, because they exhibit neither low-level resistance

nor high-level resistance and synergy with an aminoglycoside is not required in

order for penicillins to be effective?

(A) Enterococcus faecalis

(B) Staphylococcus aureus

(C) Staphylococcus epidermidis

(D) Streptococcus pneumoniae

(E) Streptococcus pyogenes

11. Your patient in the emergency room has a 5-cm ulcer on her leg that is surrounded

by a red, warm, and tender area of inflammation. You do a Gram stain on pus

from the ulcer and see gram-positive cocci in chains. Culture of the pus grows

small β-hemolytic colonies that are catalase-negative and are inhibited by

bacitracin. These results indicate that the organism causing her lesion is most

likely:

(A) Enterococcus faecalis.

(B) Staphylococcus aureus.

(C) Streptococcus agalactiae.

(D) Streptococcus pneumoniae.

(E) Streptococcus pyogenes.

12. The Jones family of four had a delicious picnic lunch last Sunday. It was a warm

day, and the food sat in the sun for several hours. Alas, 3 hours later, everyone

came down with vomiting and nonbloody diarrhea. In the emergency room, it was

286

found that Mrs. Jones, who prepared the food, had a paronychia on her thumb.

Which one of the following is the most likely causative organism?

(A) Enterococcus faecalis

(B) Staphylococcus aureus

(C) Staphylococcus epidermidis

(D) Streptococcus agalactiae

(E) Streptococcus pyogenes

13. A 20-year-old sexually active woman reports dysuria and other symptoms of a

urinary tract infection. Gram stain of the urine reveals gram-positive cocci.

Which one of the following sets of bacteria is most likely to cause this infection?

(A) Staphylococcus aureus and Streptococcus pyogenes

(B) Staphylococcus saprophyticus and Enterococcus faecalis

(C) Streptococcus agalactiae and Staphylococcus epidermidis

(D) Streptococcus pneumoniae and Enterococcus faecalis

(E) Streptococcus pyogenes and Streptococcus pneumoniae

14. Your patient is a 2-week-old infant who was well until 2 days ago, when she

stopped feeding and became irritable. She now has a fever to 38%C, developed a

petechial rash all over her body, and is very difficult to arouse. In the emergency

room, a blood culture and a spinal tap were done. Gram stain of the spinal fluid

showed gram-positive cocci in chains. Culture of the spinal fluid on blood agar
revealed β-hemolytic colonies that grew in the presence of bacitracin and

hydrolyzed hippurate. Which one of the following is the most likely causative

organism?

(A) Staphylococcus aureus

(B) Streptococcus agalactiae

(C) Streptococcus mutans

(D) Streptococcus pneumoniae

(E) Streptococcus pyogenes

15. Your patient is a 50-year-old woman who has a community-acquired pneumonia

caused by Streptococcus pneumoniae. Antibiotic susceptibility tests reveal an

MIC of less than 0.1 μg/mL to penicillin G. Which one of the following is the best

antibiotic to treat the infection?

(A) Clindamycin

287

(B) Gentamicin

(C) Metronidazole or doxycycline

(D) Penicillin G or levofloxacin

(E) Vancomycin

16. Your patient is a 70-year-old man with endocarditis caused by Enterococcus

faecalis. Which one of the following is the best combination of antibiotics to treat

the infection?

(A) Azithromycin and trimethoprim-sulfamethoxazole

(B) Chloramphenicol and rifampin

(C) Doxycycline and levofloxacin

(D) Metronidazole and clindamycin

(E) Penicillin G and gentamicin

ANSWERS
1. (C)

2. (E)

3. (D)

4. (B)

5. (D)

6. (E)

7. (A)

8. (D)

9. (D)

10. (E)

11. (E)

12. (B)

13. (B)

14. (B)

15. (D)

16. (E)

1. Regarding the differences between Neisseria meningitidis (meningococci) and

Neisseria gonorrhoeae (gonococci), which one of the following is the most

accurate statement?

(A) Meningococci are oxidase-positive, whereas gonococci are not.

(B) Meningococci have a thick polysaccharide capsule, whereas gonococci do

not.

(C) Meningococci have lipid A, whereas gonococci do not.

(D) Meningococci produce penicillinase, whereas gonococci do not.

(E) Meningococci synthesize IgA protease, whereas gonococci do not.

2. Your patient is a 14-year-old girl who was sent home from school because she

had a fever of 102°C, a severe headache, and was falling asleep in class. When
302

her fever rose to 104°C, her mother took her to the emergency room, where a

blood pressure of 60/20 and several petechial hemorrhages were found. Gramnegative

diplococci were seen in a Gram stain of the spinal fluid. Which one of

the following is most likely to cause the fever, hypotension, and petechial

hemorrhages?

(A) Endotoxin

(B) IgA protease

(C) Oxidase

(D) Pilus protein

(E) Superantigen

3. Regarding the patient in Question 2, which one of the following is the best

antibiotic to treat the infection?

(A) Azithromycin

(B) Doxycycline

(C) Penicillin G

(D) Rifampin

(E) Trimethoprim-sulfamethoxazole

4. Regarding the differences between Neisseria meningitidis (meningococci) and

Neisseria gonorrhoeae (gonococci), which one of the following is the most

accurate statement?

(A) Humans are the reservoir for both organisms.

(B) Many clinical isolates of meningococci produce β-lactamase, but clinical

isolates of gonococci do not.

(C) Meningococci have multiple antigenic types, but gonococci have only one

antigenic type.

(D) The conjugate vaccine against gonorrhea contains seven types of the pilus
protein as the immunogen.

(E) The main mode of transmission for both organisms is respiratory droplets.

5. Your patient is a 20-year-old man with a urethral exudate. You do a Gram stain

of the pus and see gram-negative diplococci with neutrophils. Which one of the

following is the best antibiotic to treat the infection?

(A) Ceftriaxone

(B) Gentamicin

303

(C) Penicillin G

(D) Trimethoprim-sulfamethoxazole

(E) Vancomycin

ANSWERS

1. (B)

2. (A)

3. (C)

4. (A)

5. (A)

1. Which one of the following is a club-shaped, gram-positive rod that causes

disease by producing an exotoxin that kills cells by inhibiting elongation factor-2,

resulting in the inhibition of protein synthesis?

(A) Bacillus anthracis

(B) Bacillus cereus

(C) Clostridium perfringens

(D) Corynebacterium diphtheriae

(E) Listeria monocytogenes

2. Which one of the following is a large gram-positive rod that causes necrosis of

tissue by producing an exotoxin that degrades lecithin, resulting in the lysis of cell
membranes?

(A) Bacillus anthracis

(B) Bacillus cereus

(C) Clostridium perfringens

(D) Corynebacterium diphtheriae

(E) Listeria monocytogenes

3. Which one of the following sets of bacteria causes disease characterized by a

pseudomembrane?

(A) Bacillus anthracis and Listeria monocytogenes

(B) Bacillus cereus and Clostridium perfringens

(C) Bacillus cereus and Clostridium tetani

(D) Corynebacterium diphtheriae and Clostridium difficile

(E) Corynebacterium diphtheriae and Listeria monocytogenes

4. Disease caused by which one of the following sets of bacteria can be prevented

328

by a toxoid vaccine?

(A) Bacillus anthracis and Clostridium botulinum

(B) Bacillus anthracis and Clostridium perfringens

(C) Bacillus cereus and Clostridium tetani

(D) Corynebacterium diphtheriae and Clostridium tetani

(E) Corynebacterium diphtheriae and Listeria monocytogenes

5. Your patient in the pediatric intensive care unit is a 2-week-old boy with a high

fever and the signs of meningitis. Gram stain of the spinal fluid reveals small

gram-positive rods. Colonies on blood agar show a narrow zone of β-hemolysis.

Which one of the following is the most likely cause of his neonatal meningitis?

(A) Bacillus anthracis

(B) Bacillus cereus

(C) Clostridium perfringens

(D) Corynebacterium diphtheriae

(E) Listeria monocytogenes

6. Regarding the patient in Question 5, which one of the following is the best

antibiotic to treat the infection?

(A) Doxycycline

(B) Gentamicin

(C) Metronidazole

(D) Trimethoprim-sulfamethoxazole

(E) Vancomycin

7. Your patient is a 40-year-old woman with diplopia and other signs of cranial

nerve weakness. History reveals she grows her own vegetables and likes to

preserve them in jars that she prepares at home. She is fond of her preserved

string beans, which is what she ate uncooked in a salad for dinner last night.

Which one of the following is the most likely cause of this clinical picture?

(A) Bacillus anthracis

(B) Clostridium botulinum

(C) Clostridium perfringens

(D) Clostridium tetani

(E) Listeria monocytogenes

329

8. Your patient is a 30-year-old man with a 2-cm lesion on his arm. It began as a

painless papule that enlarged and, within a few days, ulcerated and formed a

black crust (eschar). He works in an abattoir where his job is removing the hide

from the cattle. A Gram stain of fluid from the lesion reveals large gram-positive

rods. Which one of the following bacteria is likely to be the cause?

(A) Bacillus anthracis

(B) Clostridium botulinum

(C) Clostridium perfringens

(D) Clostridium tetani

(E) Listeria monocytogenes

9. Your patient is a 30-year-old man who was brought to the emergency room

following a motorcycle accident in which he sustained a compound fracture of his

leg. He now has a high fever and a rapidly spreading cellulitis with crepitus in

the area of the fracture. Large gram-positive rods are seen on the exudate.

Necrotic tissue was debrided. Which one of the following is the best antibiotic to

treat the infection?

(A) Azithromycin

(B) Ciprofloxacin

(C) Gentamicin

(D) Penicillin G

(E) Vancomycin

10. Your patient is a 65-year-old woman who is several days post-op following

removal of her carcinoma of the colon. She now spikes a fever and has a cough,

and chest X-ray shows pneumonia. While being treated with the appropriate

antibiotics, she develops severe diarrhea. You suspect she may have

pseudomembranous colitis. Which one of the following is the best antibiotic to

treat the infection?

(A) Ceftriaxone

(B) Doxycycline

(C) Gentamicin

(D) Metronidazole

(E) Trimethoprim-sulfamethoxazole

330
ANSWERS

1. (D)

2. (C)

3. (D)

4. (D)

5. (E)

6. (D)

7. (B)

8. (A)

9. (D)

10. (D)

1. Your patient is a 75-year-old man with an indwelling urinary catheter following

prostatectomy for prostate cancer. He now has the sudden onset of fever to 40°C,

blood pressure of 70/40, and a pulse of 140. You draw several blood cultures,

and the laboratory reports that all are positive for a gram-negative rod that forms

red pigmented colonies. Which one of the following bacteria is the most likely

cause of this infection?

(A) Escherichia coli

(B) Klebsiella pneumoniae

(C) Proteus mirabilis

(D) Pseudomonas aeruginosa

(E) Serratia marcescens

2. You’re a public health epidemiologist who is called to investigate an outbreak of

bloody diarrhea in 16 people. You find that it is associated with eating rare

hamburgers in a particular fast-food restaurant. A culture of the remaining

uncooked hamburger grows a gram-negative rod that produces a dark purple

colony on EMB agar, which is evidence that it ferments lactose. Which one of the
following bacteria is the most likely cause of this outbreak?

(A) Escherichia coli

(B) Salmonella enterica

(C) Salmonella typhi

(D) Shigella dysenteriae

(E) Vibrio cholerae

3. Your patient has third-degree burns over most of his body. He was doing well

until 2 days ago, when he spiked a fever, and his dressings revealed pus that had

a blue-green color. Gram stain of the pus revealed a gram-negative rod that

374

formed colorless colonies on EMB agar. Which one of the following bacteria is

the most likely cause of this infection?

(A) Campylobacter jejuni

(B) Escherichia coli

(C) Haemophilus influenzae

(D) Pseudomonas aeruginosa

(E) Salmonella enterica

4. Regarding the patient in Question 3, which one of the following is the best

combination of antibiotics to treat the infection?

(A) Azithromycin plus gentamicin

(B) Doxycycline plus gentamicin

(C) Metronidazole plus gentamicin

(D) Piperacillin/tazobactam plus gentamicin

(E) Vancomycin plus gentamicin

5. Regarding the members of the family Enterobacteriaceae, which one of the

following is the most accurate?

(A) All members of the family are anaerobic, which means they must be cultured
in the absence of oxygen.

(B) All members of the family ferment lactose, which is an important diagnostic

criterion in the clinical laboratory.

(C) All members of the family have endotoxin, an important pathogenetic factor.

(D) All members of the family produce an enterotoxin, which ADP-ribosylates a

G protein in human enterocytes.

6. You’re on a summer program working in a clinic in a small village in Ecuador.

There is an outbreak of cholera, and your patient has massive diarrhea and a

blood pressure of 70/40. Which one of the following would be the most

appropriate action to take?

(A) Administer antimotility drugs to diminish the diarrhea.

(B) Administer intravenous saline to replenish volume.

(C) Administer tetracycline to kill the organism.

(E) Perform stool cultures and fecal leukocyte tests to make an accurate

diagnosis.

375

7. Your patient is a 20-year-old woman with diarrhea. She has just returned to the

United States from a 3-week trip to Peru, where she ate some raw shellfish at the

farewell party. She now has severe watery diarrhea, perhaps 20 bowel

movements a day, and is feeling quite weak and dizzy. Her stool is guaiacnegative,

a test that determines whether there is blood in the stool. A Gram stain

of the stool reveals curved gram-negative rods. Culture of the stool on

MacConkey’s agar shows colorless colonies. Which one of the following

bacteria is the most likely cause of this infection?

(A) Escherichia coli

(B) Helicobacter pylori

(C) Proteus mirabilis

(D) Pseudomonas aeruginosa

(E) Vibrio cholerae

8. Your patient is a 6-year-old boy with bloody diarrhea for the past 2 days

accompanied by fever to 40°C and vomiting. He has a pet corn snake. Blood

culture and stool culture from the boy and stool culture from the snake (taken very

carefully!) revealed the same organism. The cultures grew a gram-negative rod

that formed colorless colonies on EMB agar. Which one of the following bacteria

is the most likely cause of this infection?

(A) Helicobacter pylori

(B) Proteus mirabilis

(C) Salmonella enterica

(D) Shigella dysenteriae

(E) Vibrio cholerae

9. Your patient is a 25-year-old woman with pain on urination and cloudy urine but

no fever or flank pain. She has not been hospitalized. You think she probably has

cystitis, an infection of the urinary bladder. A Gram stain of the urine reveals

gram-negative rods. Culture of the urine on EMB agar shows colorless colonies,

and a urease test was positive. Swarming motility was noted on the blood agar

plate. Which one of the following bacteria is the most likely cause of this

infection?

(A) Escherichia coli

(B) Helicobacter pylori

(C) Proteus mirabilis

376

(D) Pseudomonas aeruginosa

(E) Serratia marcescens

10. Your patient has abdominal pain, and a mass is discovered in the left lower
quadrant. Upon laparotomy (surgical opening of the abdomen), an abscess is

found. Culture of the pus revealed Bacteroides fragilis. Regarding this organism,

which one of the following is the most accurate?

(A) A stage in the life cycle of B. fragilis involves forming spores in the soil.

(B) B. fragilis is an anaerobic gram-negative rod whose natural habitat is the

human colon.

(C) B. fragilis produces black colonies when grown on blood agar.

(D) Pathogenesis by B. fragilis involves an exotoxin that increases cyclic AMP

by ADP-ribosylation of a G protein.

(E) The toxoid vaccine should be administered to prevent disease caused by B.

fragilis.

11. Regarding the patient in Question 10, which one of the following is the best

antibiotic to treat the infection?

(A) Doxycycline

(B) Gentamicin

(C) Metronidazole

(D) Penicillin G

(E) Rifampin

12. Your patient in the gastrointestinal clinic is a 50-year-old insurance salesman

with what he describes as a “sour stomach” for several months. Antacids relieve

the symptoms. After taking a complete history and doing a physical examination,

you discuss the case with your resident, who suggests doing a urea breath test,

which tests for the presence of urease. Which one of the following bacteria does

the resident think is the most likely cause of the patient’s disease?

(A) Helicobacter pylori

(B) Proteus mirabilis

(C) Salmonella enterica

(D) Serratia marcescens

(E) Shigella dysenteriae

13. Your patient is a 35-year-old woman with epilepsy who had a grand-mal seizure

377

about 2 months ago. She comes to see you now because she has been coughing up

foul-smelling sputum for the past week. Chest X-ray reveals a cavity with an airfluid

level. Gram stain of the sputum reveals gram-negative rods, and culture

reveals black colonies that grow on blood agar only in the absence of air. Which

one of the following bacteria is the most likely cause of this infection?

(A) Bacteroides fragilis

(B) Campylobacter jejuni

(C) Klebsiella pneumoniae

(D) Prevotella melaninogenica

(E) Proteus mirabilis

ANSWERS

1. (E)

2. (A)

3. (D)

4. (D)

5. (C)

6. (B)

7. (E)

8. (C)

9. (C)

10. (B)

11. (C)

12. (A)
13. (D)

1. Your patient is a 75-year-old man who has smoked cigarettes (two packs a day

for more than 50 years) and consumed alcoholic drinks (a six pack of beer each

day) for most of his adult life. He now has the signs and symptoms of pneumonia.

Gram stain of the sputum reveals neutrophils but no bacteria. Colonies appear on

buffered charcoal yeast (BYCE) agar but not on blood agar. Which one of the

following bacteria is most likely to be the cause of his pneumonia?

(A) Bordetella pertussis

(B) Haemophilus influenzae

(C) Klebsiella pneumoniae

(D) Legionella pneumophila

(E) Pseudomonas aeruginosa

2. Regarding the patient in Question 1, which one of the following is the best

antibiotic to treat the infection?

(A) Azithromycin

(B) Ceftriaxone

(C) Gentamicin

(D) Metronidazole

390

(E) Piperacillin/tazobactam

3. Your patient is a 6-year-old boy who is complaining that his ear hurts. His mother

says this began yesterday and that he has a fever of 103°F. On physical exam, you

see a perforated ear drum that is exuding a small amount of pus. Using a swab,

you obtain a sample of the pus and do a Gram stain and culture. The Gram stain

reveals small coccobacillary rods. There is no growth on a blood agar plate, but

a chocolate agar plate supplemented with X and V factors grows small grey

colonies. Which one of the following bacteria is the most likely cause of his otitis
media?

(A) Bordetella pertussis

(B) Haemophilus influenzae

(C) Klebsiella pneumoniae

(D) Legionella pneumophila

(E) Pseudomonas aeruginosa

4. It’s time to play “What’s my name?” I am a small gram-negative rod that causes

an important respiratory tract disease. I produce an exotoxin that ADP-ribosylates

a G protein. One remarkable feature of my disease is a great increase in

lymphocytes. I don’t cause disease commonly in the United States now because of

the widespread use of the vaccine that induces antibodies against five of my

proteins, one of which is the exotoxin. The identity of the mystery organism is

mostly likely which of the following?

(A) Bordetella pertussis

(B) Haemophilus influenzae

(C) Klebsiella pneumoniae

(D) Legionella pneumophila

(E) Pseudomonas aeruginosa

5. Your patient is a 75-year-old woman with a 110 pack-year history of cigarette

smoking who now has a fever of 39°C and a cough productive of yellowish

sputum. Gram stain of the sputum shows small gram-negative rods. There is no

growth on blood agar, but colonies do grow on chocolate agar supplemented with

hemin and NAD. Which one of the following bacteria is the most likely cause of

her pneumonia?

(A) Bordetella pertussis

(B) Haemophilus influenzae

391
(C) Klebsiella pneumoniae

(D) Legionella pneumophila

(E) Pseudomonas aeruginosa

6. Your patient is a 5-year-old boy with a high fever and signs of respiratory tract

obstruction. Visualization of the epiglottis shows inflammation characterized by

marked swelling and “cherry-red” appearance. Which one of the following is the

best antibiotic to treat the infection?

(A) Ampicillin

(B) Ceftriaxone

(C) Doxycycline

(D) Gentamicin

(E) Metronidazole

ANSWERS

1. (D)

2. (A)

3. (B)

4. (A)

5. (B)

6. (B)

1. Your patient is a 10-year-old boy who has a high fever and swollen, painful

axillary lymph nodes on the left side. His mother says that he brought home a

dead rat a few days ago. You suspect he may have bubonic plague. Regarding the

causative organism, which one of the following is most accurate?

(A) It has a very low ID50.

(B) It is transmitted from rodents to humans by ticks.

(C) It is endemic primarily in the states along the East Coast of the United States.

(D) Its main virulence factor is an exotoxin that induces interleukin-2 (IL-2)
production by CD4-positive helper T cells.

(E) Infection should be treated with high doses of penicillin G intravenously.

2. Your patient is a 20-year-old man who was bitten on the hand when he tried to

break up a fight between two cats yesterday. He now has a red, hot, tender,

swollen lesion at the bite site that has spread rapidly across his hand. Which one

of the following bacteria is the most likely cause of his cellulitis?

(A) Brucella melitensis

(B) Francisella tularensis

(C) Pasteurella multocida

(D) Yersinia pestis

3. Your patient is a 30-year-old woman who reports that she has had intermittent

fever of 102°F, sweating, and fatigue for the past month or so. She has lost her

appetite and has lost about 10 pounds in that period. She enjoys eating

405

unpasteurized goat cheese. On examination, hepatosplenomegaly is detected. A

blood count reveals pancytopenia. Which one of the following bacteria is the

most likely cause of this infection?

(A) Brucella melitensis

(B) Francisella tularensis

(C) Pasteurella multocida

(D) Yersinia pestis

4. Regarding Bartonella henselae, which one of the following is most accurate?

(A) B. henselae is an anaerobic, spore-forming, gram-positive rod.

(B) The natural habitat of B. henselae is the cat’s mouth.

(C) B. henselae causes cellulitis in immunocompromised patients such as AIDS

patients.

(D) Diagnosis in the clinical laboratory depends on detecting antibodies in the

patient’s serum that will agglutinate cardiolipin.

(E) The drug of choice for B. henselae infections is metronidazole.

ANSWERS

1. (A)

2. (C)

3. (A)

4. (B)

1. Your patient is a 25-year-old homeless man who complains of a cough for the

past month. The cough is now productive of several tablespoons of bloodstreaked

sputum per day. The sputum is not foul-smelling. He has lost 10 pounds

but says that he doesn’t eat regularly. On physical exam, temperature is 38°C, and

coarse rales were heard in the apex of the left lung. An acid-fast stain of the

sputum reveals acid-fast rods. Culture of the sputum shows no growth at 7 days,

but buff-colored colonies are visible at 21 days. Of the following organisms,

which one is most likely to be the cause of this infection?

(A) Mycobacterium fortuitum-chelonae

(B) Mycobacterium leprae

(C) Mycobacterium marinum

(D) Mycobacterium tuberculosis

2. Which one of the following regimens is optimal initial treatment for the patient in

427

Question 1?

(A) Isoniazid for 9 months

(B) Isoniazid and gentamicin for 2 weeks

(C) Isoniazid and rifampin for 4 months

(D) Isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months

3. Your patient is a 70-year-old man with progressive weakness in both legs that
began about a week ago. He reports back pain and fever for the past month.

Magnetic resonance imaging (MRI) of the spine reveals destruction of the seventh

thoracic vertebra and a paravertebral mass. Surgical decompression and

debridement was performed. Histologic examination of the mass revealed

caseating granulomas, and Langhans’ giant cells were observed in the

granulomas. Gram stain revealed no organisms, but an acid-fast stain showed red

rods. Culture shows no growth at 7 days, but growth is seen at 28 days. Of the

following, which one is the most likely cause?

(A) Mycobacterium fortuitum-chelonae

(B) Mycobacterium leprae

(C) Mycobacterium marinum

(D) Mycobacterium tuberculosis

4. Your patient is a 30-year-old woman who is infected with HIV and has a low

CD4 count. She now has the findings of pulmonary tuberculosis, but you are

concerned that she may be infected with Mycobacterium avium-intracellulare

(MAI). Regarding MAI, which one of the following is most accurate?

(A) Disseminated disease caused by MAI is typically the result of decreased

antibody production, whereas disseminated disease caused by M.

tuberculosis is typically caused by reduced cell-mediated immunity.

(B) Immigrants from Southeast Asia are more likely to be infected with MAI than

with M. tuberculosis.

(C) In the clinical laboratory, MAI forms colonies in 7 days, whereas M.

tuberculosis colonies typically require at least 21 days of incubation for

colonies to appear.

(D) MAI is typically susceptible to a drug regimen of isoniazid and rifampin,

whereas M. tuberculosis is often resistant.

(E) The natural habitat of MAI is the environment, whereas the natural habitat of
M. tuberculosis is humans.

428

5. Regarding the patient in Question 4, if MAI was shown to be the cause of her

symptoms, which one of the following is the best choice of antibiotics to

prescribe?

(A) Amikacin and doxycycline

(B) Clarithromycin, ethambutol, and rifabutin

(C) Dapsone, rifampin, and clofazimine

(D) Isoniazid and gentamicin

(E) Isoniazid, rifampin, ethambutol, and pyrazinamide

6. Your patient is a 20-year-old man with a single, slowly expanding, nonpainful

scaly lesion on his chest for the past 2 months. The lesion is nonpruritic, and he

has lost sensation at the site of the lesion. He is otherwise well. He is a recent

immigrant from Central America. An acid-fast stain of a scraping of the lesion is

positive. Which one of the following diseases is he most likely to have?

(A) Cutaneous tuberculosis

(B) Fish tank granuloma

(C) Lepromatous leprosy

(D) Scrofula

(E) Tuberculoid leprosy

ANSWERS

1. (D)

2. (D)

3. (D)

4. (E)

5. (B)

6. (E)
1. Your patient is a 75-year-old woman with fever and a painful nodule on her

forearm. She also has a nonproductive cough that she says is worse than her usual

smoking-related cough. She is taking high-dose corticosteroids (prednisone) for

an autoimmune disease. Chest X-ray reveals a nodular lesion in the right upper

lobe. A biopsy of the nodule on her arm was obtained. Gram stain of the

specimen showed filaments of gram-positive rods. The rods were also weakly

acid-fast. Regarding the causative organism, which one of the following is most

accurate?

(A) Culture of the organism should be done under anaerobic conditions.

(B) The natural habitat of the organism is the soil.

(C) It produces an exotoxin that inhibits protein synthesis by ADP-ribosylation.

(D) Sulfur granules are often seen in the skin lesion.

(E) The vaccine against this organism contains the capsular polysaccharide as the

immunogen.

2. Your patient is a 20-year-old man who was in a fist fight in a bar about 3 weeks

ago. He took a punch that broke his left second molar. He now has a 3-cm

inflamed area on the skin overlying the broken tooth that is draining pus. A Gram

stain of the pus reveals gram-positive filamentous rods. The rods did not appear

red in the acid-fast stain. Regarding the causative organism, which one of the

435

following is most accurate?

(A) Infections caused by this organism occur primarily in the Ohio and

Mississippi River Valley area.

(B) The natural habitat of the organism is the soil.

(C) This organism is resistant to both penicillins and aminoglycosides.

(D) Sulfur granules are often seen in the pus located at the orifice of the sinus

tract in the skin lesion.

(E) The vaccine against this organism contains a toxoid as the immunogen.

ANSWERS

1. (B)

2. (D)

1. Mycoplasma pneumoniae is an important cause of atypical pneumonia.

Regarding this organism, which one of the following is the most accurate?

(A) Amoxicillin is the drug of choice for pneumonia caused by this organism.

439

(B) Antibody in a patient’s serum will agglutinate human red blood cells at 4°C,

but not at 37°C.

(C) Gram stain of the sputum reveals small gram-negative rods.

(D) It is an obligate intracellular parasite that can only grow within human cells

in the clinical laboratory.

(E) People with cystic fibrosis are predisposed to pneumonia caused by this

organism.

2. Which one of the following is the drug of choice for atypical pneumonia caused

by M. pneumoniae?

(A) Amoxicillin

(B) Azithromycin

(C) Ceftriaxone

(D) Gentamicin

(E) Vancomycin

ANSWERS

1. (B)

2. (B)

1. Your patient is a 65-year-old man with gradually increasing confusion and

unsteadiness while walking. A lumbar puncture revealed clear spinal fluid, a

normal glucose, and an elevated protein. There were 96 cells/mm3, of which 86%

were lymphocytes. Gram stain of the cerebrospinal fluid (CSF) was negative.

Magnetic resonance imaging (MRI) of the brain was normal. A sample of CSF

reacted with beef heart cardiolipin at a titer of 1/1024. Regarding the causative

organism of his infection, which one of the following is most accurate?

(A) It is transmitted by tick bite.

(B) Resistance to penicillin G is common, so ceftriaxone should be used.

(C) It has never been grown on bacteriologic media in the clinical laboratory.

(D) It is unlikely to be eradicated because beef cattle are a major reservoir for

the organism.

(E) A confirmatory test for this organism utilizes an agglutination reaction with

the capsular polysaccharide of the organism.

460

2. Your patient is a 20-year-old man with an erythematous, macular, nonpainful rash

on the right arm for the past 4 days. The rash is approximately 10 cm in diameter.

He also has a fever to 100°F and a mild headache. He reports hiking on several

weekends recently in New York State. You suspect the rash is erythema migrans

and that he has Lyme disease. Which one of the following is the best approach to

confirm your clinical diagnosis?

(A) Detect IgM antibodies in an ELISA assay

(B) Determine the titer in a VDRL test

(C) Gram stain and culture on blood agar incubated aerobically

(D) Gram stain and culture on blood agar incubated anaerobically

(E) Grow on human cells in cell culture and identify with fluorescent antibody

3. Assume the patient in Question 2 does have Lyme disease. Which one of the

following antibiotics is the most appropriate to treat his infection?

(A) Azithromycin or trimethoprim-sulfamethoxazole

(B) Doxycycline or amoxicillin

(C) Gentamicin or amikacin

(D) Metronidazole or clindamycin

(E) Penicillin G or levofloxacin

4. Regarding syphilis, which one of the following is most accurate?

(A) The characteristic lesion of primary syphilis is a painful vesicle on the

genitals.

(B) In secondary syphilis, the number of organisms is low, so the chance of

transmitting the disease to others is low.

(C) In secondary syphilis, both the rapid plasma reagin (RPR) and the fluorescent

treponemal antibody-absorbed (FTA-ABS) tests are usually positive.

(D) The antibody titer in the FTA-ABS test typically declines when the patient

has been treated adequately.

(E) In congenital syphilis, no antibody is formed against Treponema pallidum

because the fetus is tolerant to the organism.

5. Regarding Borrelia burgdorferi and Lyme disease, which one of the following is

most accurate?

(A) B. burgdorferi infects a larger percentage of the rodent reservoir in western

states, such as California, than in northeastern states, such as New York.

461

(B) Pathogenesis of Lyme disease is based on the production of an exotoxin that

induces interleukin-2 production by T-helper cells.

(C) The vaccine against Lyme disease contains the capsular polysaccharide of all

four serotypes as the immunogen.

(D) Close family members of those infected with B. burgdorferi should be given

ciprofloxacin.

(E) B. burgdorferi is transmitted to humans by the bite of ticks of the genus

Ixodes.

6. Benzathine penicillin G is used to treat primary and secondary syphilis rather

than procaine penicillin G. Which one of the following is the best reason for this

choice?

(A) Patients allergic to procaine penicillin G are not allergic to benzathine

penicillin G.

(B) Benzathine penicillin G has a higher minimal inhibitory concentration than

procaine penicillin G.

(C) Benzathine penicillin G penetrates the central nervous system to a greater

degree than procaine penicillin G.

(D) Benzathine penicillin G is a depot preparation that provides a long-lasting,

high level of drug that kills the slow-growing Treponema pallidum.

ANSWERS

1. (C)

2. (A)

3. (B)

4. (C)

5. (E)

6. (D)

1. Your patient is a 20-year-old man with a urethral discharge. Gram stain of the pus

reveals many neutrophils but no bacteria. You suspect this infection may be

caused by Chlamydia trachomatis. Which one of the following is the laboratory

result that best supports your clinical diagnosis?

(A) Gram stain of the pus reveals small gram-positive rods.

(B) The organism produces beta-hemolytic colonies on blood agar plates when

incubated aerobically.

(C) The organism produces alpha-hemolytic colonies on blood agar plates when
incubated anaerobically.

(D) Fluorescent-antibody staining of cytoplasmic inclusions in epithelial cells in

the exudate

(E) Fourfold or greater rise in antibody titer against C. trachomatis

2. Regarding chlamydiae, which one of the following is the most accurate?

471

(A) Lifelong immunity usually follows an episode of disease caused by these

organisms.

(B) The reservoir host for the three species of chlamydiae that cause human

infection is humans.

(C) Their life cycle consists of elementary bodies outside of cells and reticulate

bodies within cells.

(D) They can only replicate within cells because they lack the ribosomes to

synthesize their proteins.

(E) The vaccine against C. pneumoniae contains the capsular polysaccharide as

the immunogen conjugated to a carrier protein.

3. Which one of the following is the drug of choice for sexually transmitted disease

(urethritis, cervicitis) caused by Chlamydia trachomatis?

(A) Ampicillin

(B) Azithromycin

(C) Ciprofloxacin

(D) Metronidazole

(E) Rifampin

ANSWERS

1. (D)

2. (C)

3. (B)
1. Your patient is a 40-year-old woman with the sudden onset of fever to 40°C,

severe headache, and petechial rash over most of her body including the palms.

Blood cultures are negative. Unfortunately, despite antibiotics and other support,

she died the following day. An autopsy was performed, and immunohistochemical

tests on her brain tissue revealed an infection by Rickettsia rickettsii. Of the

following, which one is the most accurate?

(A) It is likely she lives in Colorado and was bitten by a tick.

(B) It is likely she lives in Colorado and was bitten by a mosquito.

(C) It is likely she lives in Virginia and was bitten by a tick.

(D) It is likely she lives in Virginia and was bitten by a flea.

(E) It is likely she lives in Connecticut and was bitten by a mosquito.

2. Regarding Q fever, which one of the following is most accurate?

(A) The causative organism is transmitted by tick bite.

(B) The natural habitat of the causative agent is the white-footed mouse.

(C) The diagnosis is made primarily by Gram stain and culture on chocolate agar.

(D) Occupations that predispose people to Q fever include veterinarians and

abattoir workers.

(E) Patients with Q fever often have a petechial rash involving the palms.

ANSWERS

1. (C)

2. (D)

1. Regarding Fusobacterium nucleatum, which one of the following is most

accurate?

(A) Its natural habitat is the soil.

(B) It is an anaerobic gram-negative rod with pointed ends.

(C) The drug of choice for infections caused by F. nucleatum is azithromycin.

(D) Laboratory diagnosis is based on detecting the ability of the exotoxin to kill
cells in tissue culture.

2. Regarding Haemophilus ducreyi, which one of the following is most accurate?

496

(A) It requires both X and V factors to grow on MacConkey’s agar.

(B) Gram stain of exudate from the lesion shows large gram-positive rods.

(C) Penicillin G is the drug of choice to treat infections caused by H. ducreyi.

(D) It causes chancroid, which is characterized by a painful ulcer on the genitals.

3. Regarding Yersinia enterocolitica, which one of the following is most accurate?

(A) It causes mesenteric adenitis, which can mimic appendicitis.

(B) It is a gram-negative diplococcus found primarily within neutrophils.

(C) It is the most common cause of enterocolitis in the United States.

(D) Its natural habitat is the human oropharynx, and there is no animal reservoir.

4. Regarding Ehrlichia chaffeensis, which one of the following is most accurate?

(A) It is transmitted primarily by mosquito bite.

(B) It forms beta-hemolytic colonies on blood agar.

(C) Its most common clinical presentation is acute meningitis.

(D) It is endemic on the islands off the coast of Massachusetts (e.g., Nantucket).

(E) It forms an inclusion body called a morula in the cytoplasm of infected cells.

ANSWERS

1. (B)

2. (D)

3. (A)

4. (E)