Microbiology

Capsule Notes
 Index
Sl.No. Chapter Pg.No.

1. Systemic Bacteriology

2. Immunology
3. Parasitology

4. Virology

5. Mycology
 9

Systemic Bacteriology
Staphylococcus
i. Causes localised pyogenic infection - like abscess, cellulitis etc. Streptococci causes
ii. +
Coagulase Eg:- Staph. aureus spreading infection and this
is due to the difference in
iii. Is a urinary pathogen causing UTI, seen in
virulence factor
(a) Diabetics
(b) Catheterisation (Instrumentation- prosthetics) Urinary pathogens
iv. Gram stain: usually belong to
1. Gram positive cocci enterobacter family
2. Grape like clusters (Divides in all planes, but daughter calls fails to separate)

v. Cultures:
1. Beta-haemolytic colonies on blood agar
 10

2. Golden yellow colonies on nutrient agar -Oil paint appearance

3. Selective media :
Selective media : special media that promotes the
a. Salt milk Agar (8~10 % NaCl) growth of a particular bacteria and inhibits the
b. Mannitol Salt agar growth of commensals. Needed for stool sample
vi. Biochemical tests: - Is a solid media
a. Catalase +
b. Tube Coagulase Test - Coagulase +

c. Slide coagulase test

Tube Coagulase test Slide coagulase test
i. Detects Coagulase enzyme i. Detects Clumping factor (surface protein)
ii. Tube coagulase i.. slide coagulase
iii. 8 types

vii. Pathogenicity -
- Causes infections
- Intoxications mediated by Staphylococcus are:
A. Toxic shock syndrome toxin (TSST)
B. Staphylococcal scalded skin syndrome (SSSS) - exfoliative toxin
C. Enterotoxin - causes food poisoning
- TSST and SSSS toxin are super antigens.
Exfoliative toxins are 2 types:
i. ET-A
ii. ET-B
 11

Q: A 7-day old newborn was admitted with fever and

exfoliative skin disease . Nikolsky’s sign was positive.
Staphylococcus aureus was isolated from umbilical
stump. Culture of blister fluid was sterile.

- Blister is toxin mediated

- Primary site of infection : Umbilicus
- Culture is sterile
- Diagnosis : SSSS/ Ritters disease
- Seen in children

TEN - Seen in older patients

Enterotoxin
i. Causes food poisoning
ii. Incubation period: 1 ~ 6 hrs (short)
iii. Heat stable protein
iv. MOA : Acts on vagus nerve (not on intestine epithelium)
v. Food products containing toxin : Meat, fish, milk and milk products
vi. Source : Food handler (carrier)

Super antigen
i. Super-antigen binds
to beta-unit of T cell
receptor (lateral
aspect) AIIMS’18
ii. As a result causes
multi-system disease.
iii. Has no epitope
specificity.
 12

Common causes of food poisoning:

Organism Incubation period Food items

i. Staphylococcus aureus 2 ~ 6 hrs Meat/ fish/ milk

ii. B. cereus (emetic type) 1 ~ 5 hrs Fried rice
iii. B. cereus 8 ~ 16 hrs Meat/ vegetables
iv. Cl. perfringens 8 ~ 24 hrs Cold/ warmed up meat dish
v. Cl. botulinum 12 ~ 36 hrs Canned meat/ fish/ vegetables
vi. Salmonella species 24 hrs Poultry/ meat/ milk
vii. V. parahemolyticus 4 hrs ~ 4 days Sea food
viii. C. jejuni 1 ~ 7 days Raw milk

viii. Toxins produced by S. Aureus

Tsst
i. Infection of mucosal/ sequestrated sites by TSST producing S. aureus
ii. TSST-1 (phage group)
iii. Multi-system disease (eg.: fever)
iv. Diagnosis:
(a) Heavy growth of S. aureus from mucosal sites
(b) Blood culture - Negative
v. Super-antigen.

Hospital infection
i. Post-op wound infection and other hospital cross infection
ii. Resistant to penicillin
iii. Leading cause of health care associated infections
iv. Most common cause of surgical wound infection
 13

In an outbreak of staph. sepsis

i. Search for carriers among hospital staff
ii. Treatment of carriers :
(a) Mupirocin
Topical application
(b) Chlorhexidine
iii. Most effective method to prevent hospital infection : Hand washing Hand washing was
iv. Carriers harbour the cocci in : introduced by
1. Anterior nares - most common Semmel Weis
2. Skin
3. Vagina
4. Axilla
5. Perineum

Mrsa
i. Gene responsible : mec A
- Converts Penicillin binding protein PBP to PBP 2a
ii. 2 types:
SCC gene = Staphylococcus
Hospital acquired Community acquired Chromosome Cassette mec
i. Multi-durg resistant i. Types 4-6 SCC mec
ii. Types 1-3 SCC mec - Gene for PVL
iii. Detection of MRSA :
- Disc diffusion test using cefoxitin (induce expression of
gene) / oxacillin

Cefoxitin

Vancomycin

- PCR for detecting mec A gene

iv. Drug of choice : vancomycin
 14

Cons
Staphylococcus epidermidis
i. Causes stitch abscess
ii. Grows on implanted foreign body
iii. Biofilm - antibiotic resistant

Staphylococcus saprophyticus
i. UTI in sexually active females
ii. Novobiocin resistant
 15

Streptococcus
i. All are Catalase -
ii. Gram positive cocci in chains/ pairs
(division occurs in single plane)

iii. Commonest pathogen - Streptococcus pyogenes

iv. Causes pyogenic infection with a tendency to spread
v. Classifications :
Based on oxygen requirement

Aerobes and facultative anaerobs Obligate anaerobes (Peptostreptococci)

Based on hemolysis

α/ β/ γ/
Viridans/ Partial Complete Non-hemolyitc

Serological classification
(Based on group specific C carbohydrate antigen)
- A.k.a Lancefield Classification
- Group A ~ H and K ~ V (20 lancefield groups)
Griffith typing
Group A Streptococcus pyogenes
Griffith types 1, 2, 3, ........
Serological typing based on M protein
- M protein hass most important virulence
factor associated with it
- Antibody against M protein is protective
- No cross protection against serotypes
(different serotypes)
 16
Antigenic cross reaction
- Antigenic cross reaction accounts for some of
the manifestations of rheumatic fever and other
streptococcal diseases

vi. Virulence factors -

1. Hemolysis :
(a) Streptolysin O
- Anti-streptolysin O (ASO) titre - Retrospective diagnosis of rheumatic fever
(b) Streptolysin S
2. Pyogenic exotoxin Q: Which of the following produces superantigen ?
- Super-antigen (a) Staphylococcus epidermidis AIIMS’20
3. Streptokinase (b) Streptococcus pyogenes
- A fibrinolysin (c) Clostridium tetani
- Break down clots in early MI (d) Vibrio cholerae
4. Deoxyribonucleases
(Streptodornase, DNAase)
- Liquifies the thick puss
- Anti-DNAase B : Retrospective diagnosis of Glomerulonephritis

vii. Respiratory Infections :

(a) Pharyngitis, Tonsillitis - sore throat
(b) Mastoiditis, Otitis media
(c) Suppurative complications (Suppurative otitis media, Suppurative adenitis
(d) Streptococcus pneumonia follows viral infection like influenza to cause pneumonia

viii. Skin and soft tissue Infections :

(i) Erysipelas - superficial lymphatic swelling
(ii) Impetigo
(iii) Pyoderma - infection of wounds, burns
(iv) Subcutaneous infections - Cellulitis, Necrotising fasciitis (Flesh eating bacteria)

ix. Culture :
(a.) On sheep blood agar
(b.) Selective media for streptococcus pyogenes - Crystal violet blood agar (inhibits
all other gram positives)
(c.) Transport media - Pikes medium
 17

Beta-
haemolytic
colonies

x. Identification :
A. Catalase -
B. Not soluble in 10 % Bile
C. Bacitracin (0.04 U) sensitive -Streptococcus pyogenes

Non-suppurative complications
- Antigenic cross reaction leads to acute rheumatic fever and acute glomerulonephritis.
Acute glomerulonephritis
i. Caused by a few nephritogenic strains
ii. Followed by skin infections (pyoderma)
iii. Diagnosis:
(a) Anti-DNAase B (> 300 IU/ mL) which is produced by streptococcal species
causing skin infections
(b) Anti-hyaluronidase antibodies in case of skin infections
iv. Prophylaxis :
(a) Penicillin G (for all beta-hemolytic Group A Streptococci)
(b) Erythromycin and Cephalexin for those allergic to penicillin.

Acute rheumatic fever

i. Followed by persistent or repeated streptococcal throat infection
ii. Any serotype can cause rheumatic fever
iii. Prophylaxis : Long term prophylaxis of penicillin to prevent rheumatic fever in
repeated infection.
iv. Diagnosis : ASO titre by latex agglutination (> 200 IU/ mL) - implies recent
previous history of streptococcal infection
 18

Group b streptococci

Streptococcus agalactae
i. Causes Neonatal meningitis
ii. Virulence factor : Polysaccharide capsule
iii. Catalase -
iv. Identification :
(a) CAMP test reaction
Streak of S.aureus

Streptococcus
agalactae

Blood agar

Attenuated zone
of hemolysis
Not group B
Streptococcus

(b) Hydrolyse hippurate

Causes of neonatal meningitis

i. Group B Streptococcus - Worldwide most common cause
ii. E. coli (Predominant in India - E. coli, Klebsiella)
iii. Staphylococcus aureus
iv. H. influenzae
v. Listeria monocytogenes
vi. Streptococcus pneumoniae
vii. Klebsiella species
 19

Enterococci

i. E. faecalis and E. faecium

o
ii. Relatively heat resistant bacteria (60 for 30 minutes)
iii. Non-haemolytic (γ haemolyte)
iv. Morphology :
- Gram positive oval cocci arranged in pairs at an angle to each other

v. Diagnosis test: Bile aesculin agar - visualise aesculin hydrolysis

Positive

vi. Diseases associated :

- UTI
- Wound infections
vii. VRE - Vancomycin Resistant Enterococcus
 20

Viridans group

i. Normal flora of mouth and upper respiratory tract

ii. Culture : α-lysis (greenish) on blood agar

iii. S. sanguis is associated with bacterial endocarditis (community acquired).

iv. S. mutans is associated dental caries.

Endocarditis Etiological agent

a. Native valve endocarditis Viridans streptococci, staphycocci, HACEK organisms
b. Native valve endocarditis Staphylococcus aureus, coagulase-negative
(health care associated) staphylococci (CoNS), enterococci
c. Prosthetic valve endocarditis S. aureus, CoNS, facultative gram-negative
(Hospital acquired < 2 months) bacilli,diphtheroids, fungi
d. Prosthetic valve endocarditis Viridans streptococci, staphylococci,
(Community acquired > 12 months) HACEK organisms
e. TV endocarditis in injection S. aureus
drug users
f. Left sided endocarditis in Pseudomonas aeruginosa, Candida, Bacillus,
injection drug users Lactobacillus, Corynebacterium
 21

Test Organism
a. Catalase Test To differentiate staphylococcus and streptococcus

b. Coagulase Test Staphylococcus aureus

c. Bacitracin Sensitivity Streptococcus pyogenes

d. CAMP Test Group B Streptococcus

e. Aesculin Hydrolysis Enterococcus

 22

Streptococcus pneumoniae

Q: A 45 year old man who is a known case of sickle cell disease was admitted with pyogenic
meningitis, CSF sample was taken and sent for culture

Pus cell

Gram positive
lanceolate shaped
diplococci
- Capsule not stained
Gram positive
- Capsule stained
lanceolate using :
shaped
(a) Indiandiplococci
ink - Negative staining (background is dark)
(b) Quellung reaction
- Swelling of capsule due to Capsular antisera
- A.k.a Neufeld reaction (Neufeld Quellung)
- Culture on blood agar : Alpha lytic colonies on further incubation shows Draughtsman or
carrom-coin appearance.

Carrom-coin appearance Quellung reaction

Meningitis in children
i. H. influenza : 2 mon ~ 2 yrs (commonest age group affected)
ii. N. meningitis
iii. Streptococcus pneumoniae

Meningitis in adults
i. N. meningitis
ii. Streptococcus pneumoniae
 23
Meningitis in elderly
i. Streptococcus pneumoniae
ii. S. aureus
iii. E. coli, Proteus, Klebseilla

Q: Commonest cause of bacterial meningitis in a 1 year old child is AIIMS’20

- Pneumococcus

Pneumococcus is the single most prevalent causative agent pneumonia and otitis media in
children

i. Pathogenicity :
- Extremes of ages are affected
- When host resistance is lowered
ii. Prophylaxis :
- Adults - Polyvalent polysaccharide vaccine (capsular antigens 23 most prevalent serotypes)
- Indication : Vaccine for children (13 valent conjugate vaccine) at 2, 4, 6 months
Booster at 12 ~ 15 months
iii. Treatment :
- Parenteral penicillin/ amoxicillin (if sensitive)
- Erythromycin, tetracycline, 3rd generation cephalosporins
- For highly resistant strain - Vancomycin

Pneumococcus Streptococcus
viridans
i. Bile solubility Positive Negative

ii. Inulin fermentation Positive Negative

iii. Optochin sensitivity Positive Negative

iv. Pneumococcus is pathogenic to mice (Mouse pathogenicity testing)

- Transformation (Griffith experiment)
 24

Meningococci and Gonorrhoea

- Gram positive diplococci, Oxidase positive and aerobic bacterias
Meningococci
i. Causes cerebrospinal meningitis and meningococcal septicaemia
ii. Spread from nasopharynx through olfactory nerve or through blood stream/ conjunctiva
iii. Morphology :
- Polysaccharide capsule

- At least 13 serogroups present

- A, B, C, Y, W-135 : important serogroups causing human infections
iv. Clinical presentation :
- As erythematous macular and petechial rash which can later become purpuric or necrotic

Characteristic feature of meningococcal

septicaemia

v. Complication :
(a) Blindness/ deafness/ chronic meningitis
(b) Waterhouse-Friderichsen syndrome - adrenal haemorrhage
vi. Pathogenicity - due to LPS
 25

vii. C5 - C9 deficiency favours the disease

viii. Selective media - Modified Thayer Martin media
ix. Treatment :
- Intravenous penicillin G
- Chloramphenicol/ Ceftriaxone
x. Prophylaxis :
(a) Rifampicin/ Ciprofloxacin -for contacts
(b) Vaccine containing polysaccharides of groups A, C, W-135 and Y (no group B)

Q: A 22 year old man presented with high grade fever and purpuric rash. CSF showed gram
negative diplococci. Which is the most probable etiological agent ?
a) E.coli
b) Pseudomonas aeruginosa
c) Streptococcus pneumoniae
d) Neisseria meningitidis

Neisseria gonorrhoea
i. Causes gonorrhoea
ii. Pili helps in adhesion to mucosal surface
iii. Endotoxin - lipopolysaccharide
iv. Selective media - Thayer Martin media
v. Morphology :
- Kidney shaped appearance, adjacent sides of diplococci are concave
- Gram negative

vi. Spread by sexual contact - STD

- Urethritis in men
- Urethritis and cervicitis in women
 26

- Watercan perineus
- multiple discharging sinuses surrounding the peri-urethral area
- Vulvovaginitis in pre-pubertal girls
- Ophthalmia neonatorum
(a) Non-venereal infection
(b) Prevented by Crede’s method (Crede’s silver nitrate drops)
vii. Treatment : Ceftriaxone/ Ciprofloxacin/ Doxycycline/ Azithromycin
- Penicillinase enzyme is produced, so penicillin is not given

Q: A patient presents with urethral discharge. A gram stained smear is made from the
discharge. What is the most likely organism ?
a) Trichomonas
b) Neisseria
c) Chlamydia
d) Gardenerella

Non-gonococcal urethritis
- Non-specific urethritis
- Caused by -
i. Chlamydia trachamatis - most common
ii. Mycoplasma hominis/ Ureeaplasma urealytica
iii. Herpes virus/ Cytomegalovirus
iv. Gardenerella vaginalis/ Acinetobacter
Hemophilus ducreyi does
v. Candida albicans not cause urethritis, it
vi. Trichomonas vaginalis causes chancroid.
- Mechanical/ chemical irritation
 27

Q: A group of school students went on a picnic. They had custard from a local restaurant and
5 hours later, presented with nausea, vomiting and diarrhoea. Which is NOT true about
the condition ?
a) Pathogenesis due to heat stable preformed toxin
b) Food handlers are the source of infection
c) Beta lactam antibiotics are given, if sensitive
d) Toxin stimulates vagus nerve

Q: Which is NOT a toxin mediated staphylococcal disease ?

a) Toxic shock syndrome
b) Ritter’s disease
c) Food poisoning
d) Endocarditis

Q: A 28 year old woman presented to gynaecology OP with complaints of dysuria and frequency
of micturition. Urine culture was done and a gram positive cocci was isolated. See the tests and
find out the most probable organism ?
a) S. epidermidis
b) S. hyicus
c) S. haemolyticus
d) S. saprophyticus

No

TEST STRAIN
CONTROL TEST
Sensitivity testing using Novobiocin disc
 28

Q: Griffith typing of streptococci is based on

a) M protein
b) Capsule
c) C carbohydrate
d) Bile solubility

Q: Which is NOT a super-antigen ?

a) Toxic shock syndrome toxin
b) Streptokinase
c) Streptococcal pyrogenic exotoxin
d) Staphylococcal enterotoxin

Q: Which test is useful in identification of Streptococcus pyogenes ?

a) Catalase negative
b) Aesculin positive
c) Bacitraicn sensitive
d) CAMP test positive

Q: A 15 days old newborn presented with poor feeding, lethargy and seizures. From the CSF
sample a catalase negative, gram positive cocci which hydrolyses hippurate was isolated.
Which of the following is WRONG about the condition ?
a) Human pathogenic strains posses a polysaccharide capsule
b) Late onset meningitis is acquired from the environment
c) CAMP factor is a phospholipase
d) 92 % are Bacitracin sensitive
Answer: 92 % are Bacitracin sensitive
Early onset within 2 weeks after birth
Late onset - acquired - long term complication with sequelae.
 29

Q: Which is NOT true about enterococci ?

a) Aesculin hydrolysis positive
b) Cause UTI and intra-abdominal abscesses
c) Uniformly sensitive to penicillin
d) Heat tolerant

Q: A 3 year old boy has fever, vomiting and headache of 3 days duration. On examination he
had neck stiffness. CSF study showed elevated proteins, reduced sugar and predominant
neutrophils. Which of these is NOT likely to be associated with the condition ?
a) Streptococcus pneumoniae
b) Neisseria meningitidis
c) Hemophilus influenzae
d) Pseudomonas aeruginosa

Q: Pneumococcus is different from viridans streptococci in that the former is

a) Catalase negative
b) Not bile soluble
c) Non-capsulated
d) Optochin sensitive

Q: Which of these is NOT a causative agent of non-gonococcal urethritis ?

a) Chlamydia trachomatis
b) Mycoplasma hominis
c) Gardnerella vaginalis
d) Moraxella catarrhalis
 30

Gram Positive Bacilli

Q: A 3 year old girl from a tribal area presented with fever and difficulty in swallowing. The
tonsillar pillars were covered with a white discharge. A throat swab was taken and sent for
culture.

i. Gram stain : gram positive

Cuneiform arrangement seen - V or L shaped arrangement
- Chinese pattern

ii. Intracellular storage granules are present

- Stained by Albert’s stain, Ponder’s, Neisser’s stain.
- Metachromatic granules are better visualised by Albert’s stain (bluish black granules, green bacilli)
- Albert’s stain ingredients : Malachite green, Toluidine blue, Alcohol, Glacial acetic acid.
 31

Q: A patient has thick grey membrane on tonsils and throat followed with fever, chills.
Microscopic examination of the pharyngeal swab showed gram positive organism.
The constituents of the special stain used to stain the sample are :
a) Crystal violet, grams iodine
b) Toluidine blue, malachite green, glacial acetic acid
c) Carbol fuchsin, acid alcohol, methylene blue
d) Methylene blue

iii. Culture :
(a) Culture medium for Corynebacterium diphtheriae : Loeffler’s serum (growth occurs
in 6 ~ 8 hrs)
(b) Tellurite blood agar - grows black colonies

Metallic black coloured colonies

iv. Virulence test : for toxins produced

- Elek’s gel precipitation test/ Klebs Loeffler’s Bacillus

v. Presentation :
1. Faucial diphtheria - commonest presentation
2. Asymptomatic carriers are the commonest source of infection - nasopharyngeal skin carriers.
 32
vi. Complications:
(a) Asphyxia
(b) Acute circulatory failure
(c) Post-diphtheric paralysis (palatine, ciliary nerve)
- Spontaneous recovery of nerve damage - is the rule
(d) Mechanical complications are due to the membrane and, systemic effects are
due to the toxin
vii. Toxin
- Coded by Tox + or Beta phage
- 0.1 mg/ L Iron is the optimum concentration for toxin production
- MOA of toxin :
Elongation factor-2 is inhibited
(peptide chain elongation is inhibited)

Protein synthesis is inhibited

- Toxin has affinity to myocardium, adrenals and nerve endings
viii. Prophylaxis :
- DPT vaccine at 6, 10, 14 weeks
16 ~ 24 months
- DT vaccine at 5 ~ 6 years
ix. Treatment :
(a) Penicillin
(b) Antitoxin (20,000 ~ 100,000 units)
(c) Erythromycin (treatment for carriers)
 33

Sporogenous Rod shaped Bacteria

1. Bacillus - aerobic
2. Clostridia - anaerobic
Bacillus

i. B. anthracis - causes anthrax used as a bioterrorism agent

B. cereus - food borne gastroenteritis
ii. Gram positive, aerobic, spore producing rod shaped bacteria

Bacillus anthracis
i. Virulence factors :
(a) Capsular polypeptide
(b) Anthraox toxin
ii. Staining :
- Capsule - blood smears are
stained with polychrome
methylene blue
- M’Fadyean’s reaction
iii. Zoonotic disease
iv. Presentation:
(a) Cutaneous
Aka- Malignant pustule
- Hide Porter’s disease
(b) Pulmonary M’Fadyean’s reaction Capsule demonstration :

Aka- Wool Sorter’s disease Amorphous purplish material seen around anthrax
(c) Intestinal
v. Diagnosis - Antigen detection in tissue extracts :
(a) Ascoli’s Thermoprecipitin test
- Antigen of anthracis bacilli
vi. Selective media : PLET medium
vii. Treatment : Doxycycline
Ciprofloxacin
 34

Bacillus cereus
- Causes food poisoning
(i) Diarrhoeal type
- Cooked meat
- Incubation period : 8 ~ 16 hrs
(ii) Emetic type
- Fried rice
- Incubation period : 1 ~ 5 hrs

Clostridium
i. Gram positive anaerobic, spore forming bacilli
ii. Causes Tetanus, Gas gangrene, food poisoning
Clostridium perferinges (aka Clostridium welchii) causes gas gangrene
Clostridium difficile causes Antibiotic associated colitis (aka Pseudomembranous colitis).
Classification based on diseases
a. Gas gangrene C. perfringes, C. septicum, C. novyi
b. Tetanus C. tetani
c. Food poisoning
(1) Gastroenteritis C. perfringes type A
(2) Necrotising enteritis C. perfringes type C
(3) Botulism C. botulinum
iii. Arrangement of spores : Tennis racket appearance
Drumstick appearance
 35
Club shaped appearance

Classification of clostridia based on their spores

Spore Shape Example
Subterminal Club C. perfringens
Spherical & terminal Drum stick C. tetani
Oval & terminal Tennis racket C. tertium

- Tonic musclar spasm seen in tetanus is known as Opisthotomus.

Tetanus
i. Caused by Gram positive bacilli
ii. Characterised by tonic muscular spasm
iii. Opisthotonus is a patient suffering from tetanus

iv. Acquired infection

v. Mode of transmission :
 36

a) Wound infection - puncture wounds

b) Septic abortion
c) Applying cow-dung on umbilical stump
d) Otogenic tetanus following otitis media (local suppuration)
vi. First Symptom : Trismus
vii. Toxin :
- C. tetani is a non-invasive pathogen producing toxins
- Toxins are responsible for the pathogenesis
Bacteria enters via puncture wound

Multiplies at local site and remains there

Toxin alone travels to CNS via axons

Blocks synaptic inhibitions at spinal cord
Blocks GABA - Glycine (inhibitory)

Tonic muscular spasms

- Types of toxins :
(1) Hemolysin
- Tetanolysin
(2) Neurotoxin
- Tetanospasmin
- Responsible for pathogenesis (Virulence factor)
(3) Neurotoxin (non-spasmogenic, peripherally active)
viii. Pathogenicity :
- Toxins blocks inhibitions in the spinal cord
- Toxins act at inhibitory terminals that use GABA and Glycine as neurotransmitters
ix. Prophylaxis :
Antibiotics in wound puncture
Wound with contamination Human Anti-Tetanus Immunoglobulin is given
Passive immunisation - Human Anti-tetanus Immunoglobulin
Active immunisation - TT vaccine
Combined immunisation - Passive and active immunisation together
 37
Gas gangrene
i. Rapidly spreading edematous myonecrosis
ii. Caused by C. perfringens, C. novyi, C. septicum
iii. Incubation period : 7 hrs ~ 6 weeks

iv. Treatment :
- Surgical debridement followed by antibiotics
- Antibiotics - Penicillin and Clindamycin for 10 ~ 14 days

Clostridium perfringens
i. Also known as C. welchii
ii. Gram positive bacillus, anaerobic
iii. Capsulated, non-motile
iv. Characteristic feature :
a. Absence of spores in materials from pathological lesions
(Spores produced only in artificial cultures)
b. Scanty pus cells and diverse bacterial flora in gas gangrene
Nagler reaction
i. Specific neutralisation of α toxin
(lecithinase) by antitoxin.
ii. Neutralisation reaction (Toxin -
Antitoxin reaction).
iii. Toxin produces Opalescence
(opacity = halo)
 38

Reverse camp test

- Presence of an arrow-shaped zone of hemolysis pointing towards C. perfringens
 39

Clostridium botulinum
i. Causes botulism
- Paralytic disease presenting as a form of food poisoning
ii. Gram positive, non-capsulated, motile bacilli (peritrichate flagellate)
iii. Strict anaerobe
iv. Toxin :
- Powerful exotoxin produced
- Produced intracellularly, released on death and autolysis of the cell
- Most toxic substance known
- Neurotoxin
- Pressure cooking/ boiling for 20 min - inactivates the toxin
- Acts by blocking the production/ release of acetylcholine at the synapses and
neuromuscular junctions.
v. Clinical features :
a) Diplopia
b) Dysphagia
c) Dysarthria
d) Death due to respiratory paralysis
e) Botulism
- Food borne botulism - canned food
- Wound botulism
- Infant botulism Wound Botulism

Food-borne botulism
i. Ingestion of preformed toxin
ii. Preserved food (meat and meat products, canned vegetables/ fish)
iii. Incubation period : 12 ~ 36 hrs
iv. Features are:
1. Vomiting
2. Thirst
3. Constipation
4. Ocular paresis
5. Difficulty swallowing
6. Difficulty speaking
7. Difficulty breathing
8. Descending paralysis occurs
 40
Infant botulism
i. A.k.a Toxico-infection
ii. In infants below 6 months
iii. Honey consumption
- spores are ingested
- reaches the intestine
- toxins are produced
iv. Clinical features:
a) Constipation
b) Floppy baby - loss of
head control
c) Altered cry
d) Lethargy
e) Poor feeding
f) Pooled oral secretions

Clostridium difficile
i. Unusual difficulty in isolating Poison

ii. Gram positive bacillus, long and slender Spore

iii. Large, oval, terminal spores

iv. Ingestion of spores
v. . - Clindamycin
Antibiotic associated colitis Flagella
- Ampicillin
(Pseudomembranous colitis)
- Lincomycin
vi. Treatment : (a) Metronidazole - drug of choice
(b) Vancomycin and Bacitracin
 41

Non-Sporing Anaerobes
- Cocci
- Bacilli
- Spirochetes
- Predominant normal flora of humans
Bacterial vaginosis

i. Poly microbial infection

ii. Mobiluncus (along with Gardenerella vaginalis)
iii. Features :
- pH > 4.5
- Clue cells (epithelial cells studded with bacteria) are present
- Adding KOH to vaginal discharge to attenuate the foul smell :
Positive Amine test

Bacteroides
i. Bacteroides fragilis is the commonest non-sporing anaerobe isolated
ii. Capsular polysaccharide
iii. Produces endotoxin/ lipopolysaccharide
iv. Treatment - Metronidazole
 42
Vincent’s angina
i. Ulcero-gingivo-stomatitis
ii. Leptotrichia buccalis (A.k.a Vincent’s fusiform bacillus/
fusobacterium fusiform)
- part of normal flora
- along with Borrelia vincenti (spirochete)
iii. Differential diagnosis : Diphtheria

Nocardia
i. Aerobic
ii. Filamentous Gram positive, some are acid-fast bacilli
iii. Presentation :
1. Cutaneous infections
2. Subcutaneous infections
- actinomycotic mycetoma
3. Systemic infections

Branched acid-fast bacilli

 43

Actinomycetes
i. A. israelii
ii. Anaerobic
iii. Actinomycosis (Cervicofacial - sulphur granule
discharge, thoracic, abdominal, pelvic)
iv. Filamentous gram positive bacilli
v. Culture : Spidery colonies
- Molar tooth appearance
v. Treatment : Penicillin
- Mycetoma : Actinomadura (aerobic)

Filamentous gram positive bacilli

Molar tooth appearance

 44

Q: A patient presents with mobile, warm to touch nodule on the neck. Below are
the colonies got on anaerobic culture of the biopsy specimen. On gram staining,
it showed gram positive branching rods. What is the drug of choice ?
a) Doxycyline
b) Cotrimoxazole
c) Penicillin
d) Surgical drainage

Q: Which is NOT true about diphtheria toxin ?

a) Cardiac damage is reversible, but damage to nerve is permanent
b) Toxin is coded by tox + or beta phage
c) 0.1 mg/ L iron is optimum for toxin production
d) Inhibits polypeptide chain elongation by inactivating the elongation factor; EF-2

Q: Which is NOT true about C. tetani ?

a) Toxin contributes to invasiveness
b) Otitis media can lead to tetanus
c) Opisthotonus is characteristic
d) Tetanospasmin contributes to pathogenesis

Q: Which is NOT true about gas gangrene ?

a) Scanty pus cells and diverse bacterial flora
b) Nagler reaction is used for toxin detection
c) Spores in materials from pathological lesions is characteristics
d) C. perfringens is the commonest organism causing gas gangrene

Q: A patient developed diarrhoea following treatment with clindamycin. Which is

the WRONG statement about the condition ?
a) Intake of preformed toxin results in disease
b) An enterotoxin and a cytotoxin is produced
c) Metronidazole is the drug of choice
d) Stool culture is the most sensitive test
 45

Q: Commonest pathogenic non-sporing anaerobe isolated from humans ?

a) Bacteroides fragilis
b) Eubacterium
c) Mobiluncus
d) Lactobacillus

Q: A 35 year old lady developed infective endocarditis following dental extraction.

Which will be the most probable etiological agent ?
a) Streptococcus sanguis
b) Staphylococcus aureus
c) E. coli
d) Pseudomonas aeruginosa

Exotoxin Endotoxin
i. Actively produced by Gram positive i. Part of cell wall of Gram negative
ii. Antitoxin can be given ii. Pyrogenic effects
iii. Protein iii. LPS (lipid A)
iv. Heat labile iv. Heat stable
v. Secreted by cells, diffuse into media v. No enzymatic action
vi. Enzymatic action vi. Non specific effect
vii. Specific pharmacological effect vii. No specific affinity
viii. Specific tissue affinities viii. Large doses
ix. Active in minute doses ix. Weakly antigenic
x. Highly antigenic x. Neutralisation ineffective
xi. Neutralised by antibody

- Gram negatives producing Exotoxins are :

a V. cholerae
b E. coli (ETEC)
c Shigella
 46

Immunology
Immunity
Immunity

Innate/ Native Acquired/ natural

immunity immunity
- Vaccination

Active Passive
i. Long lasting i. Immediate protection
ii. Immunological memory ii. Preformed antibodies
iii. Immediate response are given
iv. Secondary response iii. Eg : Ig
v. Eg : TT

- Natural active immunity : Exposing body to any disease (antigen) naturally

Eg : Chicken pox (any disease)
- Artificial active immunity : following a vaccine
- Natural passive immunity : trans-placental (Ig G)
- Artificial passive immunity
Eg : Hepatitis B Immunoglobulin
- Combined immunisation = Active + Passive immunisation
(Never give passive immunisation alone)

Local immunity
i. A.k.a Mucosal immunity
ii. Ig A antibody (secretory)
iii. Examples :
a) Intestinal
b) Respiratory
 47
Herd immunity
- Total herd
- So that epidemics and pandemics
doesn’t occur
- Example :
a) Measles
b) Pulse Polio immunisation
- Increase herd immunity

Antigens

Light chain
Heavy chain

Antigen Antigen
Stimulates
introduced
antibody
parenterally
production

Antigen reacts with antibody specifically

and in an observable manner

i. Antigen : Any foreign substance which induce immunity

Stimulates antibody production = Immunogenicity
It reacts with antibody = Immunological reactivity
- Complete Antigen = both immunogenicity and immunological reactivity is present.
ii. Hapten : Immunogenicity is not present
Cannot produce antibody
Can react with already formed antibodies.
 48

iii. Epitope : Smallest unit of antigenicity

Part of antigen which makes actual contact with anitbody
iv. Paratope : Corresponding part on antibody which makes contact with antigen

Hapten + Carrier molecule Hapten becomes immunogenic

v. Heterophile antigens (Heterogenetic test)

- Antigens shared between totally unrelated groups of organsims
- Example : (a) Weil Felix Reaction
- Protein antigen similar to rickettsial antigen used for diagnosis of Rickettsiae
(Rickettsial virus is hard to culture)
(b) Paul Bunnel Test
- Sheep RBC used for diagnosis of EBV
Antibodies

- Antibody activity associated with gamma-globulin fraction

- Gamma-globulin is produced by plasma cells
- Immunoglobulins are glycoproteins
Fraction Relx G/ dL
Albumin 59.2 4.38
Alpha 1 2.7 0.20
Alpha 2 9.7 0.72
Beta 9.6 0.71
Gamma 18.6 1.39
 49
Structure of immunoglobulin

Hinge region

Light chain

Heavy chain

- 2 heavy chains linked to each other by disulphide bonds

- 2 light chains on either side of heavy chains
- Hinge region : Helps to bind to antigen (flexibility is provided)
- Antigen binding site : Aminoterminase (NH2 group)
Binds to antigen
- Carboxy terminase : Fix to cells like mast cells
Fc region

Constant & variable regions

- Heavy chain = 1 Variable region (VH) and 3 constant region (CH 1 to CH 3)
- Light chain = 1 variable region (VL) and 1 constant region (CL)
- Variable region : Amino acid sequences are variable
In order to bind with different antigens
Gives diversity to antibody
- Hypervariable region (Complementarity Determining Region) :
- Variability will be maximum
- Maximum sequence variation
50
 51
Nomenclature of antibody
- Is based on Heavy chain that it posses
- Example :
Heavy chain - α, γ, δ, ε, μ
Light chain - κ, λ

- Structure is not same for all the antibodies

- Ig M : has 5 immunoglobulin molecules
- Ig A :
(i) Secretory Ig A - Dimer, present on mucosa
(ii) Serum Ig A - Monomer
 52

Ig g
i. Equally distributed in Intra- and Extra-vascular.
ii. Major immunoglobulin, 80% of immunoglobulins
iii. Transplacental transfer
iv. Anti-Rh antibody/ Anti-D is Ig G
(When mother is Rh negative and child is Rh positive, Anti-Rh
antibody is given)
v. Neutralisation is better mediated by Ig G
vi. Types :
Ig G 1 - 65%, maximum distribution
G2
G 3 - Complement fixation is better mediated by Ig G3
G4

Ig e
i. Immunity in helminthic infections
ii. Anaphylaxis - Type 1 hypersensitivity reaction is mediated by Ig E

Ig a
i. Structure : Secretory Ig A is a dimer
Serum Ig A is a monomer
ii. Activates alternative complementary
pathway
iii. Types :
Ig A 1
Ig A 2
 53
Ig m

i. A.k.a Millionaire molecule (molecular weight

approaches a million)
ii. Major intravascular antibody in septicaemia -
intravascular distribution
iii. Immunological reactions are better performed by
Ig M (except Neutralisation is better mediated by Ig G)
iv. Earliest antibody produced by foetus - produced from 20 weeks of gestation.
(In case of congenital infections like rubella - Ig G is not taken as it could be
passively received from the mother and not produced by the neonate )
v. Anti- A and Anti-B antibodies
- are Ig M
- Isohaemagglutinins

Affinity maturation
INICET’2O
Pools of B-cell clones
High affinity B-cell clone

SHM Clonal
B-cell process selection

Antigens

- Affinity maturation antibodies gain increased affinity and anti-pathogen activity due to somatic
hypermutation (SHM) of immunoglobulin genes.
 54

Germinal centre
T cell zone

B cell zone

Activated antigen
specific B cell
No antigens bound
with VH & VL zone
Dark Apoptosis of low L
affinity B cells ight zo
Shm ne

Survived

CSR
Memory B-cell
Plasma cell
1. Antigen bound to activated T cell and FDC
2. Follicular dendritic cells (FDC) present antigen to B-cells Antigen
3 & 4. B-cell progeny that have undergone somatic hypermutation, which can
bind to an antigen with lower affinity will be out competed and gets deleted. T cell
5. B-cell progeny with the highest affinity for antigen gets selected to survive.
Follicular
- Occurs in the germinal centre’s of secondary lymphoid organs. dendritic cell
- Occurs in 2 inter-related processes:
(a) Somatic Hypermutation (SHM)
i. Mutations within the variable regions of immunoglobulin genes
(b) Clonal Selection
i. B-cells that have undergone somatic hypermutation competes for limited growth
resources, including the availability of antigen.
 55

Antigen-antibody reaction

i. Precipitation
- After antigen antibody reaction precipitates are formed which settles down
ii. Flocculation
- Type of precipitation reaction (Antigen is soluble)
- Precipitates do not settle down but will remains suspended as floccules
- Eg : VDRL (-Slide flocculation)

Precipitation Agglutination
- Soluble antigen reacts with antibody - Insoluble antigen reacts with antibody

Lattice hypothesis

Antigen-Antibody reaction
Excess molecules of
Number of antigen antigen or antibody
Visible effects required and antibody molecule
should be equal
No visible reaction occurs
Precipitation
Agglutination Visible reaction
- occured Implying negative result.

Zone phenomenon
i. Zone of equivalence: Lattice formation occurs and the reactions are visible
ii. Prozone phenomenon: Caused by excess of antibody - failure of a visible reaction
(No lattice formation)
iii. Post-zone phenomenon : Caused by excess of antigen - no visible reaction.

- Prozone and post-zone phenomena is corrected by making serial dilutions,

thereby reducing the number of molecules of antigen or antibody to get a positive
reaction by lattice formation
56
 57
Application of precipitation
i. Sensitive in antigen detection
ii. Forensic application (blood/ seminal stains)
iii. Food adulterants
iv. Ring test
v. Slide flocculation test - VDRL
vi. Tube flocculation test - Kahn test

Ouchterlony procedure
- Double diffusion in 2 dimensions
 58

a) Identical antigen b) Antigens are different c) Cross reactive

Counter immunoelectrophoresis
- Electric current is applied, so that Ag-Ab reaction can be visualised.

Rocket electrophoresis
- Quantitative detection of Antigen.
- Peaks have different heights
- Greater the height --> Higher concentration of antigens
 59

Agglutination
i. Lattice hypothesis
ii. Applications :
(a) Slide agglutination test
- Eg : Blood grouping
(b) Tube agglutination
- Eg : Widal test
(c) Heterophile agglutination tests

Coombs test
- A.k.a Antiglobulin tests
- Checks Anti-Rh antibody from mother is present or not in new born
- Incomplete antibody
- Antibody (Anti-Rh) binds with antigen (Rh positive cells) but no visible reaction occurs

(Foetal)

(Maternal)
 60

Direct Coombs test

First pregnancy : Mother is Rh negative
Foetus is Rh positive

Mother starts producing Anti-Rh antibodies

Second pregnancy : Foetus is Rh positive

Mother (Rh negative) contains Anti-Rh antibodies

Anti-Rh antibodies binds with Foetal RBCs Sensitising RBC in-vivo

Incomplete antibody No visible reaction

Adding Coombs reagent to Foetal RBC

Causes agglutination of RBCs (visible reaction)

inDirect Coombs test

- Detects anti-erythrocyte antibodies in serum.

Maternal serum Rh negative

Anti-Rh antibody (Anti-D) present

1
Add Rh positive RBCs Sensitising RBC in-vitro
2
Add Coombs Reagent
 61

Passive agglutination
i. For detecting antibodies (sensitive method)
ii. Precipitation reaction converted to agglutination
(Soluble Insoluble antigen by adding a carrier protein)
iii. Example :
Latex agglutination - For CRP, ASO
Rose Waaler Test - Passive haemagglutination
 62
Elisa
Types of ELISA :

Micro-titre plate

Q: Which of the following is the enzyme conjugate ?

a) 1 - Substrate
1
b) 2 - Enzyme conjugate
c) 3
2 d) 4

4
 63

Immunochromatography
- Card Test

Control Control
Test Test
 64

Q : What is the principle of the given test ?

a) ELISA
b) Immunofluoresence
c) Neutralisation
d) Immunochromatography

Q : The following is true about exotoxin -

a) Is lipopolysaccharide
b) Heat stable
c) Active in large doses
d) It is secreted by cells

Q : Which of the following is NOT true ?

a) Acquired immunity is by virtue of genetic and constitutional make up
b) Active immunity has immunological memory
c) Passive immunity is less effective than active immunity
d) Preformed antibodies are given for passive immunity

Q : Hapten is -
a) Smallest unit of antigenicity
b) Incomplete antigen
c) The region on the antibody that binds with antigen
d) Capable of inducing antibodies

Q : Paul-Bunnell test in infectious mononucleosis is an example for -

a) Heterophile antigen
b) Sequestered antigen
c) Isospecific antigen
d) Organ specific antigen
 65

Q : VDRL test for syphilis is an example for -

a) Slide agglutination test
b) Tube agglutination test
c) Tube flocculation test
d) Slide flocculation test

Structure & functions of immune system

- Cell mediated immunity (lymphocytes)

- Humoral immunity (antibodies)

- Central/ primary lymphoid organs : Thymus, Bone Marrow

- Peripheral lymphoid organs : Spleen, Lymph node, MALT organs, Peyers patches

Lymphoid organs

Central Periphery
Even without antigenic Produced following an
exposure T cells and B cells antigenic exposure
are produced
Immunocontegence
 66

- Development of T cells and B cells occur in the bone marrow

- Maturation of T cells occurs in Thymus
- Maturation of B cells occurs in BM itself

T cells

Cytotoxic cell Helper cell Memory cell

- A.k.a Cytolytic cell (Tc) (Th cell) (Tm)
- CD 8 marker - A.k.a Inducer cell
- CD 4 marker

Th 1 cell Th 2 cell
- Mediates cell mediated immunity - Mediates humoral immunity
- Cytokines produced : IL-2, INFγ - IL-4, 5, 6 produced (B cell stimulating factors)

- Universal marker for T cells are CD-3

B cells

Plasma cells Memory cells

- Synthesise antibodies

- CD markers for T cells are CD 3, CD 4/ CD 8

- CD markers for B cells are CD 19

Null cells
i. Lack surface markers of T and B cells
ii. Example :
Natural Killer cell (NK cell)
- Markers : CD 16, 56
- Role : Immunity against viruses, malignant cells
 67
iii. No MHC restrictions
iv. Part of innate immune system
v. Cytotoxicity is not antibody dependant
vi. No prior antigenic contact required

Phagocytic cells
- Mononuclear macrophages of blood & tissues and polymorphonuclear microphages
Macrophages Microphages
i. Monocytes/ blood macrophages i. Example - PMNL’s
ii. Tissue macrophages
- Example : Kupffer cells in liver
iii. Function :
(a) Phagocytosis
(b) Antigen processing and presentation
(c) Anti-tumour activity & Graft rejection
Phagosome forming Lysosome
Damage and digestion

Phagosome Phagolysosome Bacteria destroyed

by lytic enzymes
 68
Processing of antigens
1. Antigen is up-taken by APC
MHC

T cell

Antigen
TCR
Peptides CD 4
MHC
MHC 3. Peptide is
loaded onto MHC
and presented
Peptides to TCR on the
APC
membrane of
APC T cell

MHC RESTRICTION
2. Antigen is processed and
digested into peptide fragments

- Dendritic cells : APC with no phagocyte action

- Langerhans cells : APC on skin
 69

Major histocompatibility complex

i. Rejection of allograft
ii. A.k.a Human Leukocyte Antigen complex
iii. 3 classes :
I - Histocompatibility & Tissue graft rejection
II - Immune Response
III - Components of complement system, TNF
iv. HLA complex loci on chromosome : short arm of chromosome 6

Hla class i
i. Seen on surface of all nucleated cells
ii. Important in :
- Graft rejection
- Cell mediated cytolysis
iii. Peptide part (9 amino acids - present between α1 and α2) presents the
antigen to T cell

NH
NH

COOH

COOH
 70
Hla class ii
i. Seen only on cells of the immune system
ii. Involved in Graft versus host response : graft mounts an immune Allograft
response against the host Rejection :
iii. Peptide part (13 ~ 25 amino acids - present between α1 and β1) Host rejects
presents the antigen to T cell the graft
GVH :
Graft rejects
the host
N N
H H

COOH COOH

Hla typing uses MHC Restriction

i. Paternity dispute - T cell will recognise antigens only when its
ii. Organ transplantation presented bound to MHC
iii. HLA-B 27 (Ankylosing spondylosis) - CD 4 cells will recognise when presented
iv. HLA- DR 4 (Rheumatoid arthritis) through MHC class II
- CD 8 cells only when presented through
MHC class I

- IL-1 is produced by activated macrophages.

 71
Activation of t cells
IL-1

IL-2, 4, 5, 6

T cells and b cells in antibody production

IL-4, 5, 6 Humoral
immune
response

Memory cell

Q : Function of CD4 T cells are all except ?

a) Antibody production
b) Cytotoxicity of T cells
c) Memory B cells
d) Opsonisation
 72

Monoclonal antibodies
- Clone of cells producing antibodies against single antigen/ antigenic
determinant
- Hybridoma technology used to clone monoclonal antibodies.

Hybridoma technology
Hybridomas : Somatic cell hybrids produced by fusing antibody forming spleen cells and
myeloma cells
 73

Hypersensitivity

i. Priming dose/ Sensitising dose First exposure to antigen

No manifestation

ii. Shocking dose Second exposure

All clinical manifestations occur

Mechanism of anaphylaxis

Chemical
mediated
release
 74

- Cell fixed antibody : Even in the absence of detectable circulating antibody is

relevant in anaphylaxis

Type ii hypersensitivity reaction

i. Examples : AIHA, HDN, Drugs
ii. Cytolytic/ Cytotoxic

Type iii hypersensitivity reaction

- Immune complex diseases (Ig G)
- Example : Farmer’s lung and other types of hypersensitivity pneumonitis
Serum Sickness
- Antigen antibody complex circulates

Type iv hypersensitivity reaction

- Delayed hypersensitivity
- T cells are involved
- Cell mediated immune response
- Lymphocytes, macrophages
- Examples : Contact dermatitis , Tuberculin test
 75

Tuberculin type
Sensitised individual

Small dose of tuberculin

given intradermally

Indurated inflammatory reaction within 48 ~ 72 hrs

Contact dermatitis

Type v hypersensitivity reaction

- Following an Ag-Ab reaction, uncontrolled activation occurs
- Eg : Long Acting Thyroid Stimulation in graves’ disease
 76

Coombs and gell classification

Type I Ig E, Antibodies fixed on Anaphylaxis

(Anaphylactic) Histamine surface of basophils Atopy
- Minutes or mast cells

Type II Ig G, Antibody mediated Haemolytic

(Cytotoxic) Complement damage anaemia
- Hours/ days

Type III Ig G, Antigen-antibody Arthus reaction,

(Immune complex) Complement complexes Serum sickness
- Hours/ days
Type IV T cells, Cell mediated response Tuberculin,
(Delayed Macrophages Contact dermatitis
hypersensitivity)

Immunodeficiency diseases

- Primary Immunodeficiency Disease

- Differentially developed immune cells
- Secondary Immunodeficiency Disease
- Immune response suppressed due to other reasons :
(a) HIV
(b) Immunosuppressive drugs
(c) Ageing
- Are more common than primary.

Primary immunodeficiency diseases

Humoral immunodeficiencies
i. X- Linked Agammaglobinemia
- Bruton’s agammaglobinemia
- Only males are affected
- First immunodeficiency disease
to be identified
 77
Cellular immunodeficiencies
(T cell defects)
i. Thymic Hypoplasia (Digeorge’s Syndrome)
- Endodermal derivatives of third and forth pharyngeal pouches
- Parathyroid glands are also involved
- Associated with Teratology of Fallot

Scid
- Combined B and T cell defect
- Enzyme deficiency associated : Adenosine Deaminase
(ADA) Deficiency
- Examples : Ataxia telangiectasia
Wiskott Adrich Syndrome
Disorders of phagocytosis
i. Chronic granulomatous disease
ii. Myeloperoxidase deficiency
- Associated with recurrent infection of Candidia albicans
iii. Chediak-Higashi syndrome
- Feature : Decreased pigmentation
iv. Leucocyte G-6-PD deficiency
v. Job’s syndrome
vi. Lazy leucocyte syndrome

Secondary immunodeficiency diseases

- More common
- Malnutrition, malignancy, infections, metabolic disorders, cytotoxic drugs,
AIDS, ageing
 78

Q: Which of the following is NOT a function of lymph nodes ?

a) Enlarge following antigenic stimulation
b) Proliferation and circulation of T and B cells
c) Capture and process antigen
d) Confers immunological competence on the lymphocytes

Q : The following is NOT a function of Th1 cells ?

a) Activate macrophages
b) Activate T cells
c) Promote CMI
d) Stimulate B cells to form antibodies

Q : Cell mediated immunity is NOT important in -

a) Immunity to fungi, viruses and intracellular bacterial pathogens
b) GVH reaction
c) Type IV hypersensitivity
d) Viruses infecting respiratory and intestinal tracts

Q : True statement regarding IL-1 is -

a) Principally produced by macrophages
b) Principally produced by activated B cells
c) Principally produced by activated T cells
d) Principally produced by plasma cells

Q : Which is NOT true about anaphylaxis ?

a) Circulate Ig E antibodies mediate anaphylaxis
b) Basophils and mast cells release histamine
c) Can follow insect bite
d) Adrenaline is life saving
 79

Q : An example for type III hypersensitivity is -

a) Arthus reaction
b) Atopy
c) Contact dermatitis
d) Haemolytic disease of new born

Q : First immunodeficiency disease associated with an enzyme deficiency -

a) DiGeorge’s syndrome
b) Chediak Higashi syndrome
c) Adenosine deaminase deficiency
d) Secondary immunodeficiency
 80

Parasitology
Entamoeba histolytica
i. Protozoan parasite
ii. Habitat : Caecum
iii. Exists in 3 morphological forms : Trophozoite, Precyst and Cyst (-Infective form)

iv. Life cycle is completed in one host

Transformation of a quadrinucleate metacystic stage of

E. histolytica to eight uninucleate
 81

Q : Image showing division of an organism. Identify -

a) E. histolytica
b) Giardia
c) B. coli

v. Diseases :
(i) Amoebic Dysentery (Intestinal Amoebiasis)
- Motile trophozoites with ingested blood cells (not seen in commensals)
is characteristic

- Flask shaped ulcers in caecum and sigmoido-rectal region

- Spreads laterally, reaches submucosal layer and does not progress beyond this.
- Cysteine protein enzyme precipitates the lateral spread in amoebic dysentry.

Ingested blood cells

 82

(ii) Extra-intestinal Amoebiasis

- Most commonly involves the liver
- Hepatic amoebiasis
- Anchovy sauce pus
- Only trophites seen in abscess

- In case of invasive infection, Serological tests (ELISA) are positive in

extra-intestinal amoebiasis
vi. Laboratory diagnosis :
(a) Intestinal amoebiasis
i. Microscopic and macroscopic appearance of stool
ii. Unstained saline mounts/ Iron haematoxylin stained films
iii. Sigmoidoscopy shows amoebic ulcers.

Trophozoite Precystic stage Uninucleate Binucleate Mature

Cyst Cyst Quadri-
-nucleate
cyst

(b) Hepatic amoebiasis

i. Serological tests : LFT, IHA, Latex Agglutination, CIE, ELISA
ii. Liver abscess when drained (on aspiration) will contain trophozoites in the periphery
of the abscess (Centre contains necrotic materials)

vii. Treatment : Metronidazole (Intra-/ Extra-intestinal)

 83

Nagleria fowleri
i. Pathogenic free living amoeba
ii. Causes - Primary amoebic meningoencephalitis
iii. Morphology : 3 forms
1. Flagellate
2. Amoeba
3. Cyst
iv. Life cycle :
- Young healthy adults
- Contamination with cysts in water/ flagellate form of amoeboid
- Enters through nose (olfactory) and reaches the brain
2. Amoeba

Enflagellation

Encystment

Infection by intranasal
Instillation of amoeba

Amoebae in CSF

3. Cyst
1. Flagellate

v. CSF findings almost similar to bacterial meningitis, except that trophozoites are seen.
vi. Cysts are not seen in brain CSF.
 84

Acanthamoeba

i. Causes :
(a) Granulomatous Amoebic Encephalitis (GAE)
- Space occupying lesion
- Cyst in brain
(b) Chronic Amoebic keratitis (in contact lens users)
ii. Morphology :
- No flagella form
- Cysts and trophozoite forms exists.
- Both forms can cause infection
iii. Mode of entry : through respiratory tract
iv. Affects immunocompromised individuals (including HIV)
v. Clinical features :
- Intra-cranial space occupying lesion
- Cysts can be seen in brain
 85

Balamuthia mandrillaris

- Causes : Granulomatous amoebic encephalitis (GAE)

- Almost similar to Acanthamoeba

Flagellates

Flagellates

HaemoFlagellates lumen dwelling Flagellates

i. Leishmania i. Trichomonas
ii. Giardia

lumen dwelling Flagellates

Giardia lamblia
i. Habitat : Duodenum
ii. Infectivity : High (even 10 cysts - causes infectin)
 86

Cyst
 87

iii. Giardiasis in Ig A deficient

iv. Person-to-person transmission
v. Malabsorption, traveller’s diarrhoea
vi. Entero Test : Iodine can kill parasite
vii. Duodenal aspirate is used in the diagnosis
viii. Treatment
- Metronidazole

Trichomonas vaginalis
i. Causes vaginitis, urethritis (STD)
ii. Trophozoite is infective (No cyst)
- Pear shaped
 88

iii. Selectively infects squamous epithelium

iv. Asymptomatic infection in males
v. Dysuria, severe pruritic vaginitis in females
vi. Treatment : Metronidazole (Treat the partner/ s also)
 89

HaemoFlagellates
Trypanosomes
sleeping sickness
i. African trypanosomiasis (T. brucei)
ii. T. gambiense
iii. T. rhodesiense
iv. Vector : Tsetse fly Tsetse fly

South American trypanosomiasis (Chaga’s disease)

i. T. cruzi
ii. Vector : Reduviid bug
iii. C shaped mastigote
iv. Megacolon
v. Degeneration of intramural autonomic plexus

Reduviid bug
 90

Leishmania
Visceral Leishmaniasis
Kala azar/ Dum dum fever
L. donovani complex
Zoonotic fever
Indian visceral leishmaniasis
Man is the only source of infection
Sand fly
Amastigote stage
- Seen in human
- Leishman Donovan bodies (LD bodies)
- In the cells of reticuloendothelial system
Promastigote stage
- Sandfly
- Culture : NNN medium
 91

Reticuloendotheliosis
Pathological changes : spleen/ liver/ bone marrow
Anaemia, fever, splenomegaly
HIV heightens susceptibility to visceral leishmaniasis
Post-Kala azar Dermal Leishmaniasis (PKDL)
- After 1 yr ~ 2 yrs recovery
Cell mediated immunity : low
Montenegro skin test : Absence of hypersensitivity to leishmanial antigen is seen
Negative
 92

Cutaneous leishmaniasis
Rajasthan
Oriental sore/ Delhi boil
Transmission
Montenegro skin test : positive
Treatment : Antimony preparation
 93
musculocutaneous leishmaniasis
Espundia - mucocutaneous leishmaniasis
Etiological agents - Brasiliensis and gryanesis

Malaria
Causative agents :
(i) Plasmodium vivax
(ii) P. falciparum
(iii) P. ovale
(iv) P. malariae
(v) P. knowlesi
Vector : Female anopheles
Life cycle :
Asexual phase
- Humans (intermediate)
Sexual phase
- Mosquito (Definitive host)
Human cycle :
1. Schizogony
- Pre-erythrocyte (liver cells)
- Erythrocytic (RBC’s)
- Erythrocytic
2. Gametozony
- Occurs in human beings
- Presence of gametocytes
- Carriers/ Reservoir
- Sporozoites are ineffective to humans
 94

Ring stage

Trophozoite
 95

Exoerythrocytic Schizogony
- Hypnozoite (dormant phase) in liver cells
- Responsible for relapse
- In P. vivax and P. ovale
 96

Duration of erythtocytic schizogony varies with species

- P. vivax : 48 hours (Benign tertian malaria)
- P. falciparum : 48 hours (Malignant tertian malaria)
- P. ovale : 48 hours (Ovale tertian malaria)
- P. malariae : 72 hours (Quartan malaria)
- P. knowlesi : 24 hours
97
 98

Differential features of different plasmodia of man

Feature P. vivax P. falciparum P. malariae P. ovale

Forms in Ring forms Ring forms Ring forms Ring forms

peripheral trophozoite, and trophozoite, trophozoite,
blood schizonts, gametocytes schizonts schizonts,
gametocytes gametocytes gametocytes

Ring Cytoplasm Multiple Similar to

form opposite rings in one Similar to
P. vivax P. vivax
the red blood
nucleus is cell, forms
thicker accole

Trophozoite Irregular, Compact Band Compact

amoeboid shaped

Gametocyte Spherical Sickle Similar to P. Similar to P.

shaped/ vivax, but vivax, but
crescentic smaller smaller
Infected Schuffner’s Maurer’s Ziemann’s James
erythrocyte dots clefts stippling dots

Age of
Reticulocytes All ages Old Reticulocytes
infected
erythrocytes

Duration of
erythrocytic 48 hrs 48 hrs 72 hrs 48 hrs
schizogony

Hypnozoites Yes No No Yes

 99

Complications :
i. Pernicious malaria
ii. Blackwater fever
iii. Splenomegaly
iv. Anemia
v. Tropical splenomegaly syndrome (in endemic area)
vi. Cerebral malaria

P. malariae causes nephrotic syndrome

Repeated infection

Immune complex deposition

Kidney

Nephrotic syndrome

Trophozoite induced malaria

i. Blood transfusion
ii. Congenital malaria

Q : Transfusion associated malaria has short incubation period because of presence in blood of -
a) Ookinite
b) Gametocyte
c) Sporozoites
d) Trophozoites
 100

Immunity :
Persons who lack Duffy blood group antigen
Sickle cell trait, Haemoglobin F, G-6-PD deficiency, HLA-B 53
Laboratory diagnosis :
- Gold standard investigation - PBS
- Demonstration of parasite in blood
- Thick and thin blood smears are made
- Thick film : sensitive
- Thin film : species identification
- Stained with giemsa stain
- Quantitative Buffy Coat test (QBC)
- Para-Sight F test : Histidine rich protein 2 : specific for P. falciparum.

- Lactic dehydrogenase dip stick test : diagnosis and cure after treatment
(only live parasites are detected)

Q : A 40 years old female presented with fever of 3 days duration. Peripheral blood smear
examination helped in diagnosing malaria. Which is the most likely etiological agent ?
a) Plasmodium ovale
b) Plasmodium vivax
c) Plasmodium malariae
d) Plasmodium falciparum
 101

Babesia

i. The first arthropod-borne disease to be identified

ii. Intra-erythrocytic parasite
iii. Tetrads of merozoites - “Maltese cross” appearance
iv. Sporozoites are the infective forms
v. Bite if Ixodid ticks (sexual cycle)

Toxoplasma gondii

i. Definitive host : Cat

ii. Obligate intracellular parasite

iii. Both sexual and asexual phases occurs in cats

iv. Infective form : Both oocysts (mature oocyst containing eight sporozoites) and tissue cyst
cause infection in humans by ingestion
 102

Risk of transmission : Third trimester

Risk of malformation : First trimester

v. Modes of Infection :
 103

Risk of transmission : Third trimester

Risk of malformation : First trimester
vi. In immuno-competent - self limiting
vii. Acquired toxoplasmosis
Congenital toxoplasmosis
i. High risk of transmission to foetus if mother acquires primary
infection in Third trimester
ii. Chorioretinitis, blindness, deafness, mental retardation, epilepsy
iii. Microcephaly, HSM, cerebral calcifications

viii. Immunity - cell mediated immunity

- Reinfection : CMI
ix. Laboratory diagnosis :
1. Microscopy
2. Isolation
3. Serology
- Sabin-Feldman dye test
- Indirect immunofluorescence
- CFT, ELISA, (Ig M, Ig G antibodies)
- The double sandwich Ig A- ELSIA (congenital infection)
x. Prevention of vertical transmission : Spiramycin given
xi. Treatment :
- Effective against tachyzoites only
- Pyrimethamine/ Sulfadiazine (for acquired)

Coccidian parasites

Isospora belli
i. Causes : Diarrhoea (severe in HIV)
 104

ii. Oocysts are infective (Acid fast, 25 m X 15 m)

Differentiate from cryptosporidium

iii. Route of transmission : Feco-oral route
iv. Site of multiplication : Epithelium of ileum
v. Treatment : Cotrimazole

Cryptosporidium
i. C. hominis, C. parvum
ii. Oocyst (food/ drink, 5 m- acid fast)
- Undergoes development in soil
iii. Food poison
iv. Traveller’s diarrhoea
- Intractable diarrhoea
v. Auto-infection - cryptosporidium

vi. Disinfection of water : sequential application of ozone and chlorine

vii. Treatment : Nitazoxamide
 105

Q : A patient who underwent renal transplantation 3 months before, came with complaints of
diarrhoea of 1 week duration. Kinyoun staining of stool sample revealed structures as shown
in the figure. Choose the true statement -

a) Pathogen does not cause auto-infection

b) C. parvum is the most common species implicated worldwide
c) Oocysts are infective as soon as it is passed in the stool
d) It is an obligate intracellular organism

Balantidium coli
Largest ciliated protozoan parasite
 106

Animal reservoir : Pig

Infective stage : cyst
Ulcers in colon (can extend to muscular coat)
Blood and mucus in stool
Trophpzoites and cysts in stool
Treatment : Tetracycline
Metronidazole
 107

Q : Match the following -

A) Balamuthia mandrillaris 1) Flagella
B) Balantidium coli 2) Cilia
C) Trichomonas vaginalis 3) Psudopod
D) Toxoplasma 4) No particular organ
a) A2, B3, C4, D1
b) A3, B2, C1, D4
c) A4, B1, C2, D3
d) A1, B2, C3, D4

Q : Which is the infective form of E. histolytica ?

a) Trophozoite
b) Precyst
c) Quadrinucleate cyst
d) Flagellar form

Q : Granulomatois amoebic encephalitis is caused by -

a) Nagleria fowleri
b) Acanthamoeba culbertsoni
c) Balamuthia mandrillaris
d) Angiostrongylus cantonesis

Q : The statement which is NOT true about Giardia lamblia is -

a) The only protozoan parasite found in the small intestine
b) Trophozoites are infective
c) Causes malabsorption and traveller’s diarrhoea
d) Enterotest is helpful in diagnosis

Q : Choose the WRONG statement about Trichomonas vaginalis -

a) Trichomoniasis is an STD
b) Cysts are infective
c) Selectively infects squamous epithelium
d) Metronidazole should be given to the patient as well as the partner
for treatment
 108

Q : Vector for cutaneous Leishmaniasis is -

a) Sandfly
b) Reduviid bug
c) Tsetse fly
d) Ixodid ticks

Q : Which is NOT true about Kala-azar ?

a) Amastigote stage is seen in man
b) LD bodies multiply in the cells of reticuloendothelial system
c) Spleen is the organ most affected
d) Promastigote stage is seen in man

Q : The intermediate host of human malarial parasite is -

a) Man
b) Anopheles mosquito
c) Culex mosquito
d) Cyclops

Q : Which form of plasmodium initiates mosquito cycle ?

a) Schizont
b) Hypnozoite
c) Gametocyte
d) Sporozoite

Q : Choose the correct statement about toxoplasmosis -

a) Trophozoite and tissue cysts are the forms in asexual multiplication
b) Oocysts are seen in cats and these are the only forms that develops in cats
c) The infective forms are oocysts
d) The freshly passed oocysts are infective
 109

Helminths
- Primitive nervous system
- Excretory system is better developed
- Do not multiply in human body
Helminths

Platypus Nematodes
- Flukes/ Tapeworm - Round worm
- Hook worm
Trematodes - flukes
Miracidium
- first larval stage
Sporocyst
Redia
Cercaria
Metacercaria
 110

Schistosomes
Blood flukes
Sexes are separate (male and female)
Miracidium , sporocyst, cercariae with forked tail
No redia stage
Circarium is infective to humans - forked tail and piercing skin
All flukes are hermaphrodites

Infective to humans
Female : resides in gynaecophoric canal of males

Female

Male
 111

Schistosoma haematobium
Vesical plexuses of veins
Snails (intermediate host)
Humans (definitive host)
Oval egg with terminal spine
Endemic Hematuria (painless
terminal hematuria)
Chronic infection associated
with bladder cancer
 112

S. mansoni
Inferior mesenteric veins
Dysentry
Ova

S. Japonicum
Oriental blood fluke
Superior mesenteric vein
Katayama fever : immune complex disease
Eggs are roundish with lateral knob

Clonorchis sinensis

Chinese liver fluke/ Oriental liver fluke

Bile stained
Intermediate host : Snail and fish
Humans : definitive host
Cholangiocarcinoma in chronic infection
 113

Fasciola hepatica
Sheep liver fluke
Most common liver fluke
Intermediate host : snail
Humans and sheep : definitive host
 114

Q : Patient presented with features of jaundice -

a) Fasciola hepatica
b) Fasciola buski
c) Paragonimus westermani
d) Clonorchis sinesis

Paragonimus westermani
Oriental lung fluke
Definitive host : humans, tigers
Intermediate host : Snails, crabs
Sputum speckled with golden brown eggs
 115

Tapeworms

Pseudophyllidean Tapeworms

Diphyllobothrium latum
Fish tapeworm
Human : Definitive host

Residues in ileum
Cyclops, fish : 2 intermediate host
Associated with pernicious anemia
Treatment : Praziquantel
 116

Q : Helminth implicated in pernicious anemia is -

a) Diphyllobothrium latum
b) Ascaris
c) Taenia solium
d) Hymenolepis nana

Cyclophyllidean tapeworms

T. solium T. saginata Diphyllobothrium latum

 117
Taenia saginata
Beef tapeworm
Unarmed tapeworm
- No hooklets
Jejunum (largest helminth)
Bladder worm/ Cysticericus bovis
In humans only adult tapeworm

Infection follows consumption of undercooked beef

Treatment : Praziquantal, Niclosamide
 118

Taenia solium
Pork worm
Jejunum
Intestinal infection

Cysticercous cellulosae/ Bladder worm

- Larval form of T. solium
- Develop both in pigs and man
 119

Autoinfection :
i. Unclean/ unhygienic personal habits
ii. Reversal of peristaltic movements (gravid segments thrown back to stomach)
iii. Consumption of food or water contaminated with eggs of the tapeworm
Cysticercus can occur even in vegetarians
- Vegetarians never develop intestinal
Ocular/ Neurocysticercosis
- Second cause of Intra-cranial space occupying lesion
(First MC cause of ICSOL is : Tuberculosis)
 120

Treatment :
(a) Intestinal Taeniasis
- Praziquantel/ Niclosamide
(b) Cysticercosis
- Praziquantel
- Albendazole
- Steroids
- Anti-epileptics
- First steroids, then anti-parasitic drugs

Echinococcus granulosus
Dog tapeworm
Dog : definitive host - adult worm is seen.
Humans and sheep : Intermediate host
Causes hydatid disease (cysts in liver/ lungs/ kidney/ spleen/ brain/ bones)
First filter : liver
Second filter : lungs

3 ~ 6 mm

Scolex Neck

Immature
Proglotids
Mature
 121

Q : Name the etiological agent of this condition -

a) Echinococcus granulosus
b) Schistosoma haematobium
c) Trypanosoma cruzi
d) Schistosoma mansoni

Hymenolepis nana
Dwarf tapeworm (45 mm)
Smallest
Most common
Infecting humans
Fecal-oral transmission
Completes life cycle in one host
Auto-infection
 122

Usually asymptomatic
Treatment : Niclosamide/ Praziquantel

Q : The following is the ovum of a helminth. Which of these is true about the helminth ?
a) Both adult and larvae are seen in humans
b) Transmission is through ingestion of infected pork
c) DOC is albendazole
d) Self limiting infection occurs
 123

Q : Trematode associated with bladder cancer -

a) Schistosoma haematobium
b) Clonorchis sinensis
c) Fasciola hepatica
d) Paragonimus westermani

Q : 40 years old man with complaints of paresis and seizures. CT head suggested
neurocysticercosis.
a) The only mode of infection is consumption of improperly cooked pork
b) Consumption of food contaminated with eggs of the parasite can
cause neurocysticercosis
c) Neurocysticercosis is never reported in vegetarians
d) When larvae of Taenia saginata develops in humans, a similar disease results

Q : Which of the statement about E. granulosus is WRONG ?

a) Cysts develop in sheep/ cattle
b) In humans, liver and lungs are commonly affected
c) It is the most common of all the cestode infections
d) The adult worm has only 3 proglottides, one immature, one
mature and one gravid.

Nematodes
Elongated, cylindrical, unsegmented worms with tapering ends
Sexes are separated

Oviparous Viviparous Ovoviviparous

Round worm Trichinella Strongyloides

Hookworm Wucheraria

Whip worm Brugia

Pin worm Dracunculus

 124

Based on location of adult in the body

Intestinal Small intestine Round worm

nematodes Hook worm
Trichinella
Strongyloides

Large intestine Whip worm

Pin worm

Tissue Lymphatics Wucheraria

nematodes Brugia

Subcutaneous Loa loa

Onchocerca
Dracunculus

Conjunctiva Loa loa

Trichinella spiralis
i. Adults in duodenum (1.5 mm by 0.04 mm)
ii. Infective form : Encysted larvae in the muscles of pigs/ other animals
- Stage of intestinal invasion (Diagnosed as food poisoning)
- Stage of muscle invasion
- Stage of encapsulation
 125

iii. Viviparous
iv. No stool sample/ microscopy has a role
 126

v. Muscles commonly involved : (a) EOM

(b) Masseters
(c) Deltoids
(d) Diaphragmatic muscles
vi. Granulomatous myocarditis - Serious complication
vii. Diagnosis : Clinical
viii. Treatment : Thiabendazole
ix. Prevention :
- Proper cooking of meat
- Avoid feeding pigs with corpses.

Whip worm

i. Trichuris trichura (45 mm)

ii. Adult worms : Cecum and appendix (30 mm ~ 45 mm male)

iii. Oviparous
iv. Bile stained, barrel shaped eggs with mucus plugs at the poles
 127
v. Route of entry : Feco-oral route
vi. Egg containing rhabditiform larvae

vii. Not a blood-feeder, blood oozes at the sites of attachment

viii. Mucous diarrhoea, chronic dysentery, abdominal pain
ix. Rectal prolapse in children
x. Treatment : Mebendazole and Albendazole
xi. Prevention : Boil and cook
 128

Round worm

i. Ascaris lumbroides
ii. Largest nematode parasite
iii. 15 ~ 30 cm males
iv. Most common

Bile stained roundworm ova in feces

v. Route of entry : Feco-oral entry

vi. Features : Adult worm in small intestine
vii. Pathological effects :
(a) Due to larvae
- Loeffler’s syndrome (larvae in sputum)
- Ascaris pneumonia
(b) Due to adult worm
- Spoliative/ nutritional effects
(PEM, Vitamin A deficiency, abnormal jejunal mucosa)
(c) Toxic effects
 129

(d) Mechanical effects

viii. Diagnosis : Stool microscopy

- Bile stained egg/ unsegmented ova
- Crescentic spaces at both walls of egg

Strongyloides stercoralis
i. 2.5 mm
ii. Duodenum, upper jejunum
iii. Ovoviviparous
iv. Infective form : Filariform larvae (third form) in the soil penetrate the skin
v. Auto-infection/ intestinal infection
vi. The minute (2mm long) parasitic adult female reproduces by parthenogenesis (without male)
130
 131
vii. Parasitic phase/ free living phase
viii. Cutaneous larva migrnas/ larva currens

ix. Hyperinfection/ generalised strongyloides : AIDS

x. Diagnosis : Stool sample with larva (Rhabditiform larvae)

xi. Treatment :
- Drug of choice - Ivermectin
- Albendazole (400 mg daily for 3 days)
xii. Prevention : Avoid barefoot
 132

Q : A 40 year old HIV positive male patient comes with odynophagia and watery diarrhoea.
An endoscopy reveals esophageal and gastric candidiasis. A wet mount of the stool of the
patient reveal the following picture
a) Filariform larvae is infective for humans,
as shown in the figure
b) Transmitted through contaminated food
and water
c) Females show parthenogensis
d) DOC is Triclabendazole

Hook worm
i. Ancyclostoma duodenale/ Nectar americans (8~11 mm)
ii. Jejunum
iii. Third stage infective filariform larvae in the soil penetrates the skin
iv. Oviparous
v. Anaemia
 133

vi. Demonstration of eggs in feces (not bile stained)

- Segmented ovum with 4 blastomeres

vii. Treatment : Albendazole/ Mebendazole

Q : Ova of a helminth. Identify the helminth ?
a) Nectar
b) Ascaris
c) Trichuris
d) Entercobius

Pin worm
i. Enterobius vermicularis
ii. Oviparous
iii. Cecum, appendix
iv. 2 ~ 4 mm males
v. 8 ~ 12 mm females
vi. Egg : Planoconvex (not bile stained)
vii. More common in developed countries
viii. Double-bulb oesophagus, three
wing-like cuticular expansions
surrounding the mouth
 134

ix. Group infections

x. Auto-infection - Intense pruritus
 135
xi. Diagnosis : NIH swab for collection of specimen from perianal area to demonstrate eggs

xii. Treatment : Pyrantal palmoate

Mebendazole

Q : Auto-infection is caused by all EXCEPT -

a) Taenia solium
b) Enterobius vermicularis
c) Hymenolepis nana
d) Ascaris lumbricoides

Not bile stained :

(i.) Nectar americanus
(ii.) Enterobius vermicularis (Pin worm)
(iii.) Hymenolepis nana (Dwarf tapeworm)
(iv.) Ancyclostoma duodenale (Hookworm)

Q : Microscopy of stool bile stained eggs in case of infection with -

a) S. stercoralis
b) A. duodenale
c) A. lumbricoides
d) N. americanus
 136

Q : Identify the organism -

a) Strongyloides stercoralis
b) Ancylclostoma duodenale
c) Ascaris lumbricoides
d) Enterobius vermicularis

Q : Match the parasites and their corresponding hosts -

A, Diphyllobothrium. 1, Sheep
B, Paragonimus. 2, Cray fish
C, Brugia. 3, Cyclops
D, Fasciola. 4 , Mansonia

a) A3, B2, C4, D1

b) A4, B1, C2, D3
c) A1, B2, C3, D4
d) A2, B3, C4, D1

GUINEA WORM
i. Dracunculus medinensis
ii. Definitive host : Humans
iii. Intermediate host : Cyclops
iv. Mode of infection : Ingestion of water with larvae
v. Prevention : Boiling water before drinking
Destruction of cyclops by chemical treatment
vi. Treatment : Antihistamines and steroids
Nitrothiazole compound (ambilhar), Niridazole
The worm can be removed by patiently twisting it around a stick
 137

Filariasis

Lymphatic filariasis Subcutaneous filariasis

i. Wuchereria bancrofti i. Loa loa
ii. Brugia malayi ii. Onchocerca volvulus
iii. Brugia timori iii. Mansonella streptocerca

i. W. bancrofti and B. malayi are both seen in Kerala

 138

Sheathed unSheathed
microfilariae microfilariae
i. Mf. bancrofti i. Mf. volvulus

ii. Mf. malayi ii. Mf. Ozzardi

iii. Mf. loa iii. Mf. perstans

iv. Mf. streptpcerca

Wucheraria bancrofti
i. Males and females (adults) lie coiled together in abdominal and inguinal lymphatics and testicular
tissues
ii. Microfilariae
- Have translucent body with blunt head and pointed tail
- They circulate in blood
- Nocturnal periodicity (Culex- night biting)
iii. Involvement of the genital lymphatics occurs almost exclusively with W. bancrofti infection
iv. Definitive host : Human
v. Intermediate host : Mosquito (Culex)

Occult filariasis
- Due to hypersensitivity to filarial antigens
- Tropical Pulmonary Esinophilia
- Microfilariae not detectable in blood
- Serological tests strongly positive
- Prompt response to DEC
 139

vi. Lab diagnosis :

(1) Demonstration of microfilaria in peripheral blood
- Night blood samples :
- Unstained film
- Stained film
- Concentration techniques : Sedimentation/ filtration
(2) DEC Provocation test
- Collect blood for microfilaria demonstration, 20 min after DEC administration

Mf. Malayi
- Nuclei clumped together

Mf. bancrofti
- Distinct nuclei
 140

vii. Prevention and control :

- Eradication of vector mosquito
- Detection and treatment of carriers - DEC 6 mg/ kg body weight daily for 12 days
( 6 days in a week)
viii. Treatment : DEC (DOC)
Active microfilanoidal

Loa loa
i. African eye worm
ii. Sheathed microfilariae, diurnal periodicity
iii. Vector : Chrysops

iv. Fugitive/ calabar swellings

v. Treatment : DEC, corticosteroids

 141

Onchocerca volvulus
i. Convoluted filaria/ blinding filaria
ii. Causes - River blindness
iii. Unsheathed/ non-periodic microfilariae
iv. Vector : Simulium
v. Onchocercoma

vi. Enucleation of nodules

vii. Treatment : Ivermectin (DOC)

Angiostongylus cantonensis

i. Rat lung worm

ii. Mode of infection : Eating infected molluscs/ raw vegetables or water contaminated with larvae
iii. Causes Eosinophilic meningoencephalitis.

Q : Which nematode is ovoviviparous ?

a) Ascaris lumbricoides
b) Strongyloides stercoralis
c) Wucheraria bancrofti
d) Trichuris trichura
 142

Q : In which nematodes the adults are seen in large intestine ?

a) Ascaris and Enterobius
b) Ancylostoma and Trichuris
c) Enterobius and Trichuris
d) Ascaris and Ancylostoma

Q : Which of these is a tissue nematode ?

a) Trichurus trichura
b) Trichinella spiralis
c) Strongyloides stercoralis
d) Dracunculus medinensis

Q : Which of the following does NOT have bile stained egg ?

a) Taenia saginata
b) Trichuris trichura
c) Ascaris lumbricoides
d) Enterobius vermicularis

Q : Which of these infections are acquired by skin-penetration of larvae ?

a) Ascaris and Ancylostoma infection
b) Trichinella and Ancylostoma infection
c) Ancylostoma and Strongyloides infection
d) Ascaris and Trichinella infection

Q : Which of these have segmented eggs ?

a) Ancylostoma
b) Ascaris
c) Trichuris
d) Enterobius
 143

Q : Guinea worm infection is acquired by -

a) Walking barefoot on soil
b) Intake of contaminated vegetables
c) Bite of female anopheles mosquito
d) Intake of water containing infective cyclops

Q : Which of these is called as ‘African eye worm” ?

a) Onchocerca volvulus
b) Loa loa
c) Mansonella
d) Dirofilaria

Q : Choose the correct statement about E. histolytica -

a) Produce flask shaped ulcers which usually penetrate the muscularis layer and
produce full thickness lesions
b) Possesses cysteine proteinases that are capable of lysing the extracellular matrix
between host cells
c) Cause severe infection in individuals with HIV/ AIDS
d) Treatment of choice for amoebic colitis is paromomycin

Q : Acanthamoeba culbertsoni -
a) Granulomatous amoebic encephalitis occurs in immunocompetent
persons, who are otherwise healthy
b) Reaches the central nervous system through olfactory nerves
c) Infection presents as a space occupying lesion
d) The absence of cysts in biopsy specimens is characteristics

Q : Which is WRING about malaria ?

a) Cerebral malaria presents as diffuse symmetric encephalopathy and focal
neurological signs are absent
b) Erythrocytic cycle of Plasmodium knowlesi takes 48 hours
c) Africans with duffy negative phenotype are resistant to Pl. vivax malaria
d) Trophozoites are the infective forms in transfusion transmitted malaria
 144

Virology
Corona virus
i. Enveloped RNA virus
ii. Petal/club shaped peplomers on the surface
iii. Causes Common cold, SARS

Severe acute respiratory syndrome

(sars)
i. In November 2002, in china
ii. Outbreaks in many countries
iii. SARS related Corona virus (SARS-CoV)
- Recombinant of animal and human coronavirus
iv. Clinical features :
- Coughing, sneezing, close personal contact
- Inhalation of aerosols
- Incubation period - 10 days
- Fever, cough
v. CXR : Pneumonia like changes
vi. Death due to respiratory failure
 145

Mers-cov
i. 2012
ii. Causes severe lower respiratory illness, gastrointestinal symptoms
iii. 30 % mortality
iv. Sources : camels and bats
v. Complications : Pneumonia, kidney failure

Sars-cov2
i. COVID-19
ii. City of Wuhan in China - ARDS
iii. Genomic and evolutionary evidence of Pangolin origin

iv. Transmission :
- Animal to human
- Human to human
- Asymptomatic carriers
- Respiratory droplets (Coughing, sneezing)
- Contact
- Aerosols in closed spaces
 146

v. Pathogenesis :
- Nasal and laryngeal mucosa

Lungs
- Virus targets organs that express ACE2 (lungs, heart, renal and gastrointestinal tract)
vi. Pathophysiology :
- ARDS - Cytokine storm
 147

Viremia phase

Acute phase (pneumonia)

Severe disease Recovery phase

Co-morbidities

vii. Clinical features :

- Fever
- Cough
- Sore throat
- Anosmia
- Shortness of breath
- Rhinorrhea - infrequent
viii. Complications :
(a) ARDS
(b) Acute respiratory failure
(c) Acute liver/ kidney injury
(d) DIC
(e) Secondary infection
(f) Neurological complications
ix. Differential diagnosis :
(a) Adenovirus
(b) Influenza
(c) Human metapneumovirus (HmPV)
(d) Parainfluenza
(e) Respiratory syncytial virus
(f) Rhinovirus (common cold)

x. Laboratory diagnosis
 148

NAATs
rRT-PCR : gold standard
True Naat : Not that sensitive (50 ~ 80 %)
BSL2 needed for molecular diagnosis
Serological tests :
- Ig M and Ig G antibodies (blood samples)
- ELISA, immunochromatography
- Accurately assess prior infection and immunity to SARS-CoV-2
Other markers :
(i) Elevated CRP
(ii) Elevated LDH, AST
(iii) Lymphopenia
(iv) Elevated ESR
(v) Increased bilirubin
(vi) Elevated D-dimer

Q : Specimen handling for molecular testing of SARS CoV 2 requires -

a) BSL-1
b) BSL-2
c) BSL-3
d) BSL-4
 149

Q : Presence of SARVSCoV2 antibodies in the serum indicates -

a) Patient is in the window period
b) Prior infection even if the patient was asymptomatic
c) High risk of infection
d) High viral load

- Smallest pathogenic virus is Parvovirus (B19)

- Largest pathogenic virus is Pox virus (also has the largest genome among pathogenic virus)
- Smallest genome among pathogenic virus : HBV
- All viruses are ultra-scopic except Pox virus
- Only virus with complex symmetry : Pox virus

- Virus having reverse transcriptase :

(a) Retrovirus
(b) Hepadnavirus

Virus classification
HSV 1 & 2
Herpesviridae EBV
CMV
Varicella zoster
HSV 6, 7, 8

Hepadenoviridae Hepatitis B virus

Enveloped
Adenovirus Human -
Dna Adenoviruses A ~ F
Double stranded
Variola virus
Vaccinia virus
Poxviridae
Cowpox
Monkeypox
Non-enveloped
Papilloma virus
Papovaviridae
Polyomavirus

Single stranded Non-enveloped Parvoviridae Parvovirus

 150
Double stranded Non-enveloped Reoviridae Human Rotavirus

Picornaviridae Enteroviruses

Non-enveloped Calciviridae Norwalk virus

Hepatitis E virus
Astroviridae Human astrovirus

Orthomyxoviridae Influenza virus A ~ C

Paramyxoviruses
Paramyxoviridae Measles virus
Single stranded RSV
Chickengunya virus
Togaviridae
Rubella virus

Yellow fever virus

Dengue virus
Rna Flaviviruridae
Japanese encephalitis virus
Hepatitis C virus
Sandfly fever
Bunyaviridae
Hantaviruses
Enveloped
LCM
Arenaviruses
Lassa fever

Rhabdoviridae Chandipura virus

Rabies virus
Coronaviridae Human coronaviruses

Retroviridae HIV 1 -2
HTLVl-2
Marburg virus
Filoviridae
Ebola virus
Deltaviruses Hepatitis
deltavirus
 151

Shape of viruses
Brick shaped Pox virus
Bullet shaped Rabies virus
Star shaped Astrovirus

Cup shaped depressions Calvivirus

Sand sprinkled appearance Arenavirus

Space vehicles Adenovirus

Wheel shaped Rotavirus

Dane particle Hepatitis B virus

Filamentous Filoviridae virus

Herring bone/ zipper like Paramyxoviridae

- Negro bodies are seen in Rabies (mostly in hippocampus and cerebellum)

- Torres bodies are seen in Yellow fever
- Cowdry A seen in Herpes, chicken pox, yellow fever
- Cowdry B seen in Adenovirus, polio virus
- Henderson Peterson bodies are seen in Molluscum contagiosum
- Guarnieri/ Paschen bodies are seen in Variola

- Oncogenesis in EBV is due to :

i. LMP-1
ii. Viral EBNA-2
- EBV associated malignancies are :
i. Burkitt’s lymphoma
ii. Nasophayrngeal carcinoma
iii. Hodgkin’s lymphoma
iv. NHL
 152
Clinical & epidemiologic features of viral hepatitis

- HBsAg :
i. First marker to be elevated following infection
ii. Indicates onset of infectivity
iii. Remains elevated in the entire duration of acute infection.
- HBeAg and HBV DNA : Markers of active viral replication and high viral infectivity.
- Anti-HBs indicates recovery and immunity. (Only marker of vaccination)
 153

Infectious causes of genital ulcer

Disease Genital Chancroid Syphilis LGV Granuloma

herpes inguinale

Aetiology HSV-2 > 1 Haemophilus Treponema Chlamydia Klebsiella

ducreyi pallidum trachomatis granulomatis
L1, L2, L3

Character- Multiple Tender, shallow, Non-tender, Painless Painless

istics painful non-ulcerated indurated small ulcer Papule/
vesicles/ ulcer ulcer nodule ulcer
ulcers Ragged edges, Raised
bleeds easily regular edge

Regional Tender Tender Non-tender, Tender, Pseudo-

LNAP Discrete Suppurative rubbery non- suppurative buboes
Non- suppurative Draining
suppurative sinuses
Groove sign
Diagnosis Tzanck smear School of DFM Miyagawa Donovan
DFAT fish DFAT NAAT bodies
Cultivation Culture NAAT Serology Bipolar
NAAT NAAT Serology staining
 154

Mycology
Classification :
- Depending on morphology, 4 classes

Yeast Moulds/
Yeasts like filamentous Dimorphic
fungi fungi fungi
- Cryptococcus
- Candida - Cause food - Has 2 morphologies :
- Produces a poisoning 1. Yeast (37 C)
pseudomycelium 2. Filamentous
form (25 C)
- Histoplasma
- Blastomyces
- Paracoccidiodes
- Penicillium marneffei
- Sporothrix schenkii

Superficial mycoses

Surface mycoses
A 30 year old man came to dermatology OP with confluent areas of discolouration on the
skin of the back.
 155

malassezia furfur
Skin scrapings taken from the lesions is shown.

Pityriasis versicolor
Spaghetti and meat balls appearance

Candida
Gram stained smear of the discharge

Pseudomycelli
Budding yeast cells
Gram stained smear of the growth on SDA
 156

Identification of growth :
(i) Gram staining
(ii) Germ tube test - Reynolds-Braude phenomenon

Q : Identify the fungus -

a) C. albicans
b) Cryptococcus neoformans
c) Histoplasma capsulatum
d) Aspergillus fumigatus

Q : An HIV positive presented with mucosal lesions as shown. Microscopy

showed budding yeast cells and pseudohyphae. What is your
diagnosis ?
a) Oral hairy leukoplakia
b) Oral Candidiasis
c) Lichen planus
d) Diphtheria
 157
Aspergillus
Lactophenol cotton blue preparation from colonies
 158
Penicillium
Brush hilar appearance

Mucor
 159
Rhizopus
Root like structure Rhizoids

Cryptococcus
Geimsa stain smear

India ink staining

- Budding yeast cells

- Capsulated
 160

Pneumocystis jirovensi
Microscopy :
i. Giemsa/ Methenamine silver stain
ii. Black cysts in methenamine silver staining
iii. Fluorescent antibody staining - honeycomb appearance of the cyst

Subcutaneous mycoses

Mycetoma
An agriculture worker from Tamil Nadu presented with history of multiple
swellings on the foot and seropurulent black discharge from the sinuses
 161

Q : A farmer presents with a swollen foot and multiple sinuses.

What is the most probable diagnosis ?
a) Mycetoma
b) Sporotichosis
c) Squamous cell carcinoma
d) Nocardia

Chromoblastomycosis

Warty lesion Sclerotic body

Sporothrix schenkii
LPCB mount of the growth on SDA
Delicate hyphae
flower
 162

rhinosporidium
A 40 years old male came with friable polyps in the oral cavity.

Fraible polyp

paracoccidioidomycosis
Multiple budding yeast cells
Mariner’s wheel
 163

Histoplasmosis
Tuberculate spores

Growth on SDA
164
165
166
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