Viruses ​ ​Bacteria​ Fungi Parasites

1.Acellular Prokaryotes Eukaryotes Eukaryotes

2.No nucleus Nucleiod region Nucleus with Nucleus with
but nuclear nuclear membrane nuclear membrane
membrane absent
3.Can be DNA & DNA & RNA DNA & RNA DNA & RNA
RNA
4.Replicates only in
host cell
6.No Ribosomes 70s Ribosomes 80 ribosomes 80 ribosomes
(50s+30s) (60s+40s)
7.Few viruses are Cell membrane Cell membrane Cell membrane
enveloped does not have contains have cholesterol
sterols. ergosterol

8.Do not have cell Bacteria cell wall is Cell wall made up No cell wall in
wall made of of chitin parasites & human
peptidoglan cells

Normal flora in body

● On Skin - Staph epidermidis

● In Nose – Staph Aureus
● Oropharynx -Strep Viridens like strep mutans
● In Stomach – No bacteria
● In Blood – No bacteria
● Colon – In babies - Bifido bacterium
o In adult - Bacteroids, Ecoli
● Vagina: Lacto bacillus

Major pathogenic mechanisms of bacteria​:

● Adherence to cell surface

 o Pili /Fimbriae are seen in most Gram –ve
o Techoic acid is seen in most Gram +ve bacteria
● Strep Pneumonia, Neisseria, and H.Influenza produce IgA proteases
● Biofilm produced by Strep mutans, Staph epidermidis

Anti-phagocytic Nature of bacteria:

● Capsule / Slime layer inhibits phagocytic uptake

● Strep pyogens has M-proteins that act as anti phagocyte component
● Pili of Neisseria gonorrhea inhibits phagocytosis
● Protein A of Staph Aureus inhibits phagocytosis by binding to FC fragment
of Ig prevents phagocytosis.
● Intracellular bacteria like Mycobacterium Tuberculosis inhibit phagosome &
lysosome fusion.
● Listeria escapes from phagosome before phagosome & lysosome fusion.

Capsulated Organisms:

Strep pneumonia, Klebsiella pneumonia, Haemophilus influenza,

Pseudomonas aeroginosa, Neisseria meningitides,Cryptococcus
neoformans, B.Anthracis, Salmonella, E.coli

Quellung Reaction:
Swelling up of capsule when specific anti serum is added, seen with all capsulated
bacteria
Toxins:
Exotoxin ​ ​Endotoxin
1.Exotoxin are protein toxin Lipopolysaccharides (LPS)
2. Secreted by gram –ve & +ve Secreted by gram –ve bacteria only
[Gram +ve bacteria- Listeria]
3. Secreted outside cell wall 3. Endotoxin are structural components
of outermember of cell wall, released
only when cell is dead or during lysis.
[Neisseria Meningitidis overproduces
endotoxin and can secrete it]
4. Heat labile 4. Heat stable
5. Immunogenic 5. Not Immunogenic
6. Toxic component are 6. Active component is lipid A
A- active component
B- Component helps to bind to
receptors

Mechanism of Action of Toxins​:

Protein synthesis inhibitors
● Diptheria Toxin has ADP ribosyl transferase activity and inactivates
elongation factor ii Major targets heart, nerves, epithelium
● Pseudomonas Aeroginosa also acts by ADP ribosyl transferase activity and
inhibits EF ii
o Primary target is Liver.
● Shiga toxin produced by shigella dysentery interferes with 60s ribosomal
subunit and inhibits protein synthesis.
● EHEC [Entero haemorrhagic E.coli] produce verotoxin called as “ shiga like
toxin” & interferes with 60s ribosome.
Neurotoxins
● Clostridium botulinum produces Botulinum toxin that inhibit release of Ach.
● Clostridium tetani produce tetanus toxin that block or inhibit the release of
inhibitory neurotransmitters.
C-AMP inducers
● C - vibrio cholera produces cholera toxin, acts by stimulating G​s​, increases
activity of adenylate cyclase that stimulate cyclic AMP
● A - Bacillus Anthracis produces anthrax toxic that makes adenylate cyclase
& increases C-AMP causes Edema
● M – ETEC [Entero Toxic E.coli] causes traveller’s diarrhoea, its heat labile
toxin stimulate G​s​, increases activity of adenylate cyclase that stimulate
cyclic AMP
● P- Pertussis toxin acts by inhibiting G​i​ prtn & C-AMP
Cyto toxins
 ● Clostridium Perfringens produces (alpha) toxins, which has lecithinase
activity that causes myonecrosis.
● Staph Aureus produces (alpha) toxins, which damages the cells
Super antigens
● Toxic shock syndrome toxin of Staph Aureus (TSST1)
● Erythrogenic toxin Strep pyogenes
Acid-fast bacilli:
1. Mycobacterium tuberculosis
2. Mycobacterium leprae
3. Legionella
4. Oocyst of cryptosporidium
5. Oocyst of isospora
Nocardia is partially acid fast.
Organism not staining with gram stain:
1. Treponema pallidum
2. Rickettsia
3. Chlamydia
4. Mycobacterium
5. Mycoplasma

Gram +ve Gram –ve

Cocci Cocci

● Staphylococcus Neisseria meningitidis/gonorrhoea

● Streptococcus Moraxella

Gram +ve Bacilli Gram -ve Bacilli

● Actinomyces E.coil
 ● Bacillus Shigella
● Corynebacterium Haemophilus
● Clostridium Salmonella
Chlamydia
● Listeria
Klebsiella
● Mycobacterium Spirochetes
● Nocardia Rickettsia

Bacterial growth curve​:

Log phase​: there is high metabolic activity without cell division
No of cells before log phase = no of cells after end of log phase
Log phase/Exponential phase​: rapid cell growth & rapid cell division.
Stationary phase​: No of new cells= no of dying cells
Nutrients start getting used up & spore formation begins in stationary phase.
Death phase​: its due to depletion of nutrients & build up of waste products.
Obligate aerobes: ​B.Anthracis, M.Tuberculosis,Pseudomonas Aeroginosa
Obligate anaerobes: ​Actinomyces, Bacteroides, Clostridium
Obligate Intracellular bacteria: ​Rickettsia, Chlamydia
Micro Aerophilic Bacteria: ​H.Pylori, Campylobacter jejuni
Urease +ve bacteria:
● Proteus, Ureoplasma, Klebsiella, H.pylori, Cryptococus neoformans,
Nocardia
Spore forming bacteria:​ Bacillus,Clostridium, Coxiella burnetii
Pigment Producing Bacteria:

● Staph Aureus produces golden yellowish pigment.

● Pseudomouas Aeruginosa produces pyocyanin & fluorescin.
 ● Actinomyces Israeli produces yellow sulphur granules
Types of Molility:
● Tumbling motility: Listeria
● Actinogenic motility: Listeria in the cells
● Swaming motility: Proteus
● Dartiling motility: Vibrio cholera, Campylobacter jejuni
● Shooting star motility: Vibrio cholera
● Cork- screw motility: Treponema pallidum
● Falling leaf motility: Giardia
Catalase +ve organisms:
● Staph Aureus,Pseudomonas aeroginosa, Aspergillus, Candida, E.coli, Listeria
Phage coded toxins:
● ShigA like toxin, Botulinum, Cholera, Diphtheria, Erythrogenic toxin of Strep
Pyogenes
Culture media: ​Basic constituents of a culture media are

• Peptone – digested proteins

• Agar – Its used to solidify the media but doesn’t have nutritional
properties. Its preffered over gelatine as gelatine melts at room
temperature
❖ Simple/Basal Media:
▪ They support growth of non-fastidious bacteria
▪ Ex: Peptone water, Nutrient agar, Nutrient broth
❖ Enriched media:
▪ When basal media is added with additional nutrients like blood, serum
or egg. It supports fastidious bacteria
▪ Ex: Blood agar, Chocolate agar, Loeffler’s serum slope
❖ Enrichment broth:
▪ Liquid media allow pathogens to grown and inhibit normal flora
▪ Ex: Selenite F & Tetrathionate broth for Salmonella & Shigella
▪ Alkaline peptone water for Vibrio cholera
❖ Selective media:
▪ Same as Enrichment broth but it’s a solid media
▪ Ex: LJ media, TCBS etc
❖ Transport media:
▪ Keep the delicate specimens viable or store them longer
▪ Ex: Pike’s, Amies, Stuart’s, VR, Cary-blair, Autoclaved sea water etc
❖ Differential media:
● Differentiate between 2 groups of bacteria
● Ex: Mac-Conkey – LF & NLF, Acid fast – AF & NAF, CLED- LF & NLF for
urine specimens, Gram – G+ & G-
● Anaerobic media:
● Ex: Robertson’s cooked meat (RCM) broth, Thioglycollate broth etc

Sterilization & Disinfection

● Sterilization: destroys all microbes including spores
● Disinfection: destroys all microbes except spores
● Asepsis: chemical agent (antiseptics) applied to body surfaces which kills
pathogenic microbes on skin
● Decontamination (Sanitization): reduction of microbes to such a level which
is safe to handle. Spores are not killed
1. Physical methods:
Heat- kills by denaturation of proteins
● Dry heat: Flaming, Inceneration, Hot air oven
● Moist heat:
● a.Temp<100 C- Pasteurization, Insipissation
● b. Temp at 100C- Boiling, steaming, tyndallization
● c. Temp>100C- Autoclave
Filteration
Radiation
● a.Ionizing radiation: X,Y & cosmic rays
● b.Non-ionizing radiation: UV and IR rays
2. Chemical methods:
● Alcohols- Ethyl alcohol
● Aldehydes- Formaldehyde
● Halogens- Iodine, Chlorine
● Oxidising agents- Hydrogen peroxide
● Dyes- Aniline and Acridine dyes
● Gas- Betapropionolactone (BPL)

Dry Heat (Hot air oven):

● Holding temp: 160C for 2 hours
● Materials sterilized:
● Glassware- syringes,petri dish,flask,test tubes
● Surgical instruments-scapels,scissors,forceps
● Chemical-liquid parrafin,gycerol etc
● Sterilization control- Nontoxic C.tetani, B.subtilis

Moist heat <100C:

● Pasteurization: used for fruit/veg juices, dairy etc.
● Holder method (63C for 30 mins)
● Flash method (72C for 20 sec followed by cooling to 13C)
● All non-sporing pathogens are killed except C.burnetii

Moist heat >100C (Autoclave):

• Temp-121C for 15 min at pressure of 15 psi
• Uses- Its used for surgical instruments and culture media & those materials
that can’t withstand the higher temp of hot air oven or media containing
water that can’t be sterilized by dry heat
 • Control- B.stereothermophilus (also for Plasma sterilization)
• Prions are most resistant. Recommended methods are
• Autoclaving at 134C for 1-1.5 hour
• NaOH for 1 hour
• 0.5% Na hypochlorite for 2 hours

Bacteriology
Gram +ve cocci.

Staphylococcus Aureus:
● Catalase (+), coagulase (+)
● Produces Beta-hemolysis.
● Its normal flora in the nasal mucosa

Virulence:

Protein A of Staph Aureus binds to F​c​ component of IgG and inhibits phagocytosis.

Extracellular enzymes:

● Coagulase
● Hyaluronidase
● Heat stable Nuclease or DNAase

Diseases caused:

● It is the M/C cause of Acute endocarditis, Acute osteomyelitis,Nosocomial

pneumonia, Surgical wound infection, Paronychia, Psoas abscess and
epidural abscess, Furnuncles, Carbuncles, Mastitis and breast abscess,
Botryomycosis
● Toxin mediated diseases are TSS, Food poisoning, Scalded skin syndrome

Toxins​:

● Cytotoxins: S.Aureus produces alpha Toxins which damages cells

 ● Enterotoxin: heat stable preformed toxin causes Gastroenteritis within 1-6
hrs by stimulating Vagus nerve and CTZ after consuming Milk products,
Potato salad, Processed meat and custards.
● Toxic shock syndrome toxin (TSST- MC Pyrogenic exotoxin C)-Common in
female using tampons presents with, Hypotension, Fever, Rash, Multi organ
failure
● Exfoliative (Epidermolytic) toxin: responsible for scalded skin Syndrome
Neonates: Ritter’s Disease
Elders: Toxic Epidermal necrosis [TEN]
Milder forms: Pemphigus neonatorum, Bullous impetigo

Dx:

Culture:

● Nutrient Agar- Golden yellow colonies

● Blood Agar – Beta hemolysis
● Selective media – Mannitol salt agar, Ludlams medium

Biochemical test

Tests differentiating S.Aureus from CONS:

Coagulase test, Heat stable Nuclease test, DNAase test, Mannitol test

Rx of Staph Aureus:

If sensitive to penicilins, then Penicillin G is DOC

If sensitive to Methicillin then Nafcillin or oxacillin is DOC

Methicillin resistance Staph Aureus [MRSA]

● Vancomycin (DOC), Teicoplanin

Vancomycin Resistance Staph Aureus [VRSA]

● Linezolid,Tedizolid, Quinpristin – Dalfopristin, Daptomycin

Staphylococcus Epidermidis:
● Normal Flora: skin
● Coagulase –ve, Novobiocin Sensitive.
● Adheres to foreign bodies like skin grafts, catheters, and prosthetic devices
● It produces a biofilm and is M/C pathogen producing endocarditis,
complicating patients of i.v catheters and exogenous implants.
● It also produces Ventricular shunt infections and stitch abscess

Staphylococcus Saprophyticus:

● It novobiocin resistance, Coagulase –ve

● It produces UTI in sexually active females

Streptococcus [catalase –Ve] on blood agar:

Alpha ​α​ -hemolysis [partial] (green color due to biliverdin):

Optochin sensitive ​ ​Optochin resistant

Strep Pneumonia/pneumococcus Strep viridans

Beta ​β​ -hemolysis (complete):

Bacitracin sensitive​ ​Bacitracin resistant

Strep pyogenes (Group A Streptococcus) Strep Agalactiae

(group B Step)

Gamma ​γ​-hemolysis (no hemolysis):

6.5% Nacl sensitive​ ​6.5% Nacl resistant

Strep bovis Enterococcus
Streptococcus Pneumoniae/Pneumococcus:
● Diplococci, Lancet/Flame shaped, bile soluble
● Alpha hemolytic, Optochin sensitive, Capuslated, IgA producing
● MCC of Lobar Pneumonia, pyogenic meningitis in all ages except Neonates
● MCC of non invasive lesion like otitis media & sinusitis in children
● Risk factors- Splenectomy, Sickle cell anemia, COPD, CHF,Viral infections
like Influenza, Alcoholism
Dx: ​Draughtsman/ Carrom coin colony on blood agar
● Latex agglutination particle test, Quellung’s reaction +ve
R​x: ​Pen G is the DOC
​Macrolides for bacteria pneumonia
Ceftriaxone for adult meningitis
Amoxicillin for otitis media, sinusitis

Prevention:

● Pneumococcal Polysaccharide Vaccine (PPV 23) for adults

● Pneumococcal Conjugate Vaccine (PCV 13)

Streptococcus Viridens:​
● Catalase –ve, alpha hemolytic, optochin resistant, bile insoluble
● They are commensals of mouth
● Strep mutans is responsible for dental plague, dental caries & produces
biofilm.
● Strep sanguis causes sub–acute bacterial endocarditis
● Infective endocarditis presents with malaise, weight loss, splinter h’ages,
night sweats, fever, heart murmurs, and Janeway’s lesion
R​x​: Pencillin G with aminoglycosides for endocarditis
B-hemolytics:
Streptococcus Pyogenes:​
● Also called as group-A streptococci.
● It is Beta-hemolytic, bacitrian sensitive, PYR+ve.
● Based on carbohydrate antigen of cell wall, its divided into 20 Lance field
groups A-V (w/o I-J)
● Group A-strep are further divided into different types based on M-proteins
[>100 griffithe types]

Virulence factors:

● Produces hyaluronidase (spreading factor)

● M-protein is anti-phagocytic, Causes Streptococcal toxic shock
● Streptolysin O: Immunogenic, Hemolysis/cytolysin,O​2​ labile, Cardiotoxic,
Poor prognostic factor
● Streptolysin S: Non-immunogenic, O​2​ stable,causes hemolysis on surface of
blood agar
● Streptokinase is fibrinolysin
● DNAase
● SPE/Erythrogenic toxin – SPE A,C are bacteriophage coaded, B is
chromosomal mediated, causes Scarlet Fever, Necrotising Fasciitis,
Streptococcal TSS
Diseases caused:
● Pharyngitis/ Sore throat, Pneumonia​, ​Acute Rheumatic fever​, ​Acute
glomerulo nephritis [PSGN]
● Skin involvement in the form of Impetigo, Cellulititis, Erysipelas, Necrotising
fasciitis
● Scarlet fever:
It is caused by erythrogenic toxin/ SPE toxin (Dick test +)
Streptococcal pharygitis accompanied by sandpaper rash, strawberry
tongue

D​x​:
Serology:

● ASO titre >200 Todd unit/ml

● Anti DNAse B >300 units/ml

Culture:

● Blood agar shows Beta hemolysis

● Selective media: Crystal violet blood agar
● Transport Media: Pike’s media
R​x:
● Pharyngitis, Impetigo, Cellulitis – Benzathine Penicillin G
● Necrotising fasciitis - Surgical debridement, Penicillin G + Clindamycin
● Pneumonia- Penicillin G
● Strep TSS – Pen G + Clindamycin + IG to SPE
● RF and PSGN – Benzathine Pen G

Streptococcus Agalactiae:
● Its Group B strep
● Reservoir is vagina/ rectum (30% women)

Diseases caused:

● Neonatal sepsis – Early onset <7 days – Pneumonia, RDS

Late onset >7d- 3m – Meningitis
● Pueperial sepsis and Peripartum fever

​Dx:

● Beta hemolytic, Bacitracin resistant, CAMP +ve.

● Hippurate test +
● Orange pigment production on Islam’s media
● R​x:
● Pencillin
γ​ -Hemolytic streptococci​:
Enterococcus
● Important species are enterococcus faecalis, Enterococcus faecium (drug
resitant)
● Reservoir​:​ normal flora of human GIT
● It causes UTI, Mitral valve endocarditis (i.v drug abusers), Late onset
Neonatal sepsis and meningitis
Dx:
● Enterococcus grows in 40% bile, grows in 6.5% Nacl, PYR +ve
● Bile aesculin test+
Rx:
● Most strains are resistant to Pens, Aminoglycosides, Sulfonamides
● Combo therapy – Pens+ Aminoglycosides (Gentamicin)
● Vancomycin in resistant cases
● VRE – Daptomycin, Linezolid, Quinupristin- Dalfopristin
● UTI – Ampicillin or Nitrofurantoin

GRAM +ve Bacilli:

Bacillus Anthracis:

● It’s a large gram +ve, non bulging spore forming, aerobic bacillus.
● Capsule is made of polypeptide [D-glutamate].
● Toxin of Bacillus Anthracis has 3 factors:
o Edema factor that acts by cyclic-AMP
o Lethal factor causes cell death
o Protective antigen

Clinical features:

Anthrax is a zoontic disease effecting herbivores. Humans became infected, when

spores are inhaled from infected animals or with contact with infected animals.
Anthrax types:

1. Cutaneous Anthrax
2. Pulmonary Anthrax
3. Gastrointestinal Anthrax

1.Cutaneous Anthrax/Hideporter’s disease (MC):

● Occurs d/t cutaneous exposure to spores

● Malignant Pustule:​ Painless black necrotic eschar

2​. Pulmonary Anthrax/Woolsorter’s disease:

● Its life threatening Hemorrhagic pneumonia

● Bacteremia (blood/lymphatic) leading to H’agic mediastinitis, H’agic
meningitis
Dx:
● Mc Fadyean reaction- capsule appears purple on staining with polychrome
methylene blue
● Gram staining – bamboo stick appearance
● Agar plate- Medusa head colony
● Gelatin stab – Inverted fur tree appearance
● Solid media with penicillin – String of pearl appearance
● Selective media – PLET media
R​x​:
● Ciprofloxacin/ doxycycline + clindamycin +/- Rifampicin
● Raxibacumab – neutralizes anthrax toxin
● Vaccine – Alum precipitated toxoid vaccine

Bacillus Cereus:
● It’s similar to bacillus anthracis, but does not show “ String of Pearls”
appearance & is motile, non-capsulated
● It causes food poisioning, keratitis
It produces 2 types of toxins:
 ● Diarrhoeal type secreted in intestine resembles toxin of Clostridium
perfringens which is heat labile producing effects in 8-16 hours on
consumption of meat, vegetables, dried beans, cereals
● Emetic type is preformed toxin resembles toxin of Staph Aureus which is
heat stable producing effects in 1-5 hours on consumption of Rice (Chinese
fried rice)
Dx: ​MYPA (Mannitol, Egg yolk, Phenol red, Polymixin agar)
Rx: ​Clindamycin, Erythromycin, Vancomycin

B.Thuringiensis- food poisoning, larvacidal agent for mosquito control

B.stearothermophilus & subtilis – control for autoclave and plasma
sterilization

Clostridum tetani:
● It’s a obligate anaerobe producing Tennis racket/drumsticks shaped
terminal spores
● Reservoir is soil, hospital, intestine of man and animals

Toxins:​ Tetanolysin, Tetanospasmin

Tetanospasmin:
● Its Oxygen stable but heat labile toxin, that inhibits the release of inhibitory
neurotransmitters presyntaptically
● Strychnine poisoning also show similar effects but acts post synaptically

Clinical features:

● Incubation period is 6-10 days.

● Presents with Trismus/Lock jaw, Risus sardonicus, Opisthotonos
● In tetanus deep tendon reflexes are exaggerated
● Tetanus patient are not infectious & there is no person to person
transmission
 ● Neonatal tetanus /8​th​ day disease – spasms with child loosing ability to suck
and cry between day 3- day 28 ( to prevent give 2 TT doses to pregnant
women in 2​nd​ Trimester one month apart)

Dx: ​Robertson’s cooked meat (RCM) broth- turns meat black and foul odor is
produced

R​x​: HTIG/ ATS, Metronidazole is DOC

Clostridium Botulinum:​
● It’s an anaerobic, Gram +ve, spore forming bacilli
● Botulinum toxin is most potent bacterial toxic known
● Botulinum toxin is coded by a prophage, acts by inhibiting the release of
Ach

Types of Botulism:

Adult food borne botulism:

● I​t’s due to the preformed toxin present in canned food, green beans, and
peas
● Symptoms usually arise 1-2 days later with Diplopia, Dysphagia, Descending
flaccid paralysis, Decreased deep tendon reflexes, Constipation, Respiratory
failure

Wound botulism:

● It is due to traumatic implantation of spores

● Resemble food poisoning without GI symptoms

Infant botulism​:

● It’s due to ingestion of botulimum spores, usually spores seen in honey.

● The toxin is produced in the gut by germinating spores leading to weakened
voice, inability to suck and swallow, ptosis and extreme weakness (Floppy
baby syndrome)
Iatrogenic botulism: ​injection of overdose of toxin

R​x​:
● Respiratory support.
● Hyperimmune serum [Botulinum immunoglobulin]
● Antibiotics generally not used

Clostridum Perfringens:
● Its gram +, non motile, capsulated bacillus
● Type A Enterotoxin produces food poisoning
Gas Gangrene:
● Its myonecrosis due to contamination of wound with soil during battle field
wounds or crushing injuries of muscle or bullet injuries
● Incubation period is 10-48 hrs (C.perfringens), 2-3 days (C.septicum), 5-6
days (C.Novyi)
● Its due to Alpha toxin (Lecithinase or Phospholipase C)
● There is edema, gas bubbles (crepitus), and dense tissue pain.
● There is high mortality rate (50%)
Dx:
Gram+ bacilli which are boxcar shaped without spore is suggestive of
C.perfringens
● Nagler’s reaction - on egg yolk agar a zone of opacity is formed on egg yolk
agar plate with no antitoxin
● Target hemolysis – double zone of Beta hemolysis
● Reverse CAMP test
● Culture media – RCM, Egg yolk agar etc

R​x​:
● Surgical debridement is most crucial step
● Penicillin & Clindamycin
● Hyperbarric oxygen
 ● Anti alpha toxin serum

Clostridium difficile:
● Its responsible for antibiotic associated diarrhoea &
pseudomembranous colitis
● Cephalosporin, Clindamycin, Ampicillin, Fluroquinolones are associated
antibiotics
● Pathogenesis is toxin mediated
● Dx: ​Demostration of toxin is more meaningful than culture
(CCFA-cefoxitin cycloserine fructose agar, CCYA-cefoxitin cycloserine
eggyolk agar) which is detected by PCR which is highly sensitive and
specific
● R​x​:​ Doc is Metronidazole alternate is Vancomycin

Non- sporing anerobes:

● Mobilincus – Bacterial vaginosis
● Bacteroides fragilis-MC commensal in gut. Causes abdominal infection
● Leptotrichia/Fusibacterium – Vincent’s angina (also by B.Vencentii)

Corynebacterium diptheriae:
● Its gram +ve club shaped noncapsulated,non-sporing rod
● In addition C.diptheriae (Kleb-Loffler bacillus) are show Chinese letter or
Cuneiform arrangement and also produces metachromatin granules aka
Volutin granules/Babes-Ernst bodies/Polar bodies on Albert’s stain

Pathogenesis:

● It spreads via respiratory droplets

● Diptheria is toxemia and toxin is coded by a prophage that acts by inhibiting
protein synthesis by inhibiting EF–II. All effects localized (respiratory) and
systemic are toxin mediated except skin lesions which are d/t organism
 ● It is not invasive it colonizes on pharynx producing a dirty
pseudomembrane that can extend onto the trachea & larynx causing
mechanical obstruction.
● Systemic effects are due to the toxin mainly damage heart, nerves &
epithelium

Respiratory Diptheria:

● M/C type is Tonsilo pharyngeal [Faucial type]

● Fever, Sore throat
● Bull neck appearance, Asphyxia
● Myocarditis
● Recurrent laryngeal nerve palsy, Peripheral neuropathies
● Cause of death is circulatory failure.

Cutaneous Diphtheria​:

● Necrotic ulcers caused by both toxogenic and non-toxogenic strains

● Its by organism itself and not toxin mediated
● The vaccine doesn’t protect from skin lesions

Dx:
● Albert stain – green bacilli with bluish black metachromatic granules
● Loeffler’s serum slope – enriched media detects growth in 6-8 hours
● Selective media – On Potassium Tellurite agar or Tinsdale media black
color colonies seen after 48 hours
C. Diptheriae Biotypes on PTA :
Gravis – Daisy head colonies (100% toxogenic – epidemics)
Intermedius- Frog’s egg colonies (90% toxogenic- epidemics)
Mitis – Poached egg colonies (80% toxogenic- endemic)
● Toxin demonstration is by Elek’s test

R​x​:
● ADS is treatment of choice
 ● Penicillin G/ Erythromycin is DOC (effective <6hrs, Cutaneous diphtheria)
● Prevention: Diptheria toxoid (single vaccine) or DPT,DaPT (combined
vaccine)
● Schick test: ​a neutralization test used to determine whether or not a person
is susceptible to diphtheria

Listeria:
● It’s a gram +ve bacillus that grows in refrigerated food esp raw milk or
spreads by vertical transmission as well
● It’s facultative intracellular produces listeriolysion O or LLO that that
disrupts the phagosome membrane & allow it to escape before phagosome
lysosome fusion with actin jet motility

Clinical presentation:

● Pregnancy: >20 weeks leads to abortions or stillbirths

● Adults: MCC of meningitis in kidney transplant patients >1 month,
gastroenteritis
● Neonates:
o Early onset (<5d)- Acquired due to obstetrical complications from maternal
genital flora. MC form is neonatal sepsis, rarely Granulomatosis
infantiseptica
o Late onset (>5d)- Acquired from environment. MC form is meningitis

​Dx:

● Catalase + showing tumbling motility at 25° and non motile at 37°

● Selective media- Palcam agar
● Anton test- instillation to rabbit eye causes conjunctivitis

Rx: ​DOC is Ampicillin alternative is cotrimoxazole

Actinomycetes:
Human pathogenic strains are Actinomyces, Nocardia and Streptomyces which
are gram+ branching filamentous bacteria

Actinomyces Nocardia

▪ Anaerobic Aerobic
▪ Non-acid fast Partially acid fast
▪ Normal flora of Gingiva In soil dust
▪ Infection is endogenous Exogenous
▪ Cervicofacial (lumpy jaw) Pulmonary, CNS, Mycetoma
▪ Sulfur granules, hard give Soft, Found mostly in mycetoma
Sunray appearance
▪ Doc penicillin Doc- cotrimoxazole

Tropheryma Whipplei​ is gram + actinomycete that causes Whipple’s disease

Erysipelothrix rhusiopathiae ​is gram + rod that causes erysipeloid skin lesion mc
on finger k/a Seal finger or Whale finger

Mycobacterium tuberculosis:
● Acid fast, obligate aerobe, weakly gram +ve

Virulence factors​:

● KAT-G​ gene encodes for Catalase

● CORD factor​: main virulence factor [Trihelose Dimycolate] that causes
serpentine growth in vitro & inhibits leukocyte migration & also disrupts
mitochondrial phosphorylation.
● Tuberculin protein​: Responsible for delayed hypersensitivity reaction
● Lipoarabinomannan(LAM)​: They help in adhesion to Macrophages and also
impairs phagosome lysosome fusion

Pathogenesis:

Primary pulmonary Tuberculosis​:

● Its d/t initial exogenous infection with tubercle bacilli
● Ghon’s focus ​➔​Ghon’s complex ​➔​Rankes complex
 Secondary T.B or Reactivational T.B:
● Its d/t Exogenous reinfection or Endogenous reactivation of latent infection
● Assmann focus is calcified nodules and Simons focus is seen at apex of lungs

C/F:

● Productive Cough,Hemoptysis,Fever,Night sweats,Cavitations,Weight loss

Extra pulmonary Tuberculosis (EPTB)​:
● It spreads by hematogenous route
● Tubercular lymphadenitis mainly in cervical & supra clavicular region is the
most common involvement followed by Pleural effusion
● Skeletal T.B m/c involves the spine called as ​Potts spine
● GI T.B commonly involves ileocecal junction
● GU T.B occurs as Renal TB and Genital TB leads to infertility
● TB CNS occurs in children as Tuberculous meningitis
● TB skin is k/a Scrofuloderma that spreads directly from lymph nodes

D​x:
● TB is stained by Acid fast stain by Zeihl-Neelsen technique or by
Auramine-rhodamine fluorescent dye.

Culture​:

● Lowenstein Jenson medium​- it is a standard solid medium used but slow

● Bactec-​ it’s a liquid medium and gives results within 2 weeks
● Molecular methods like PCR​ & Gene expert detect within a day or few
hours
Dx of latent TB
Mantoux’s/tuberculin test:
● It is done to demonstrate hypersensitivity to tuberculin protein.
● It’s an intra dermal test using purified protein derivative PPD
● The area of in duration is looked at and is said to be +ve if its >10mm & -ve
if <5mm
Interferon Gamma release assay (IGRA):
 In ELISA format its called Quantiferon TB Gold Assay it’s highly specific with
no false positives
● Rx​ - Multiple drug treatment is given as ATT. Minimum 6 months of
treatment is required for uncomplicated patients.
● HRZE is given for 2-3 months followed by HR for next 4-5 months
● MDR-TB : PAS,
Ethionamide,Amkacin,Cycloserine,Capreomycin,Bedaquilline,Linezolid,Oflo
xacin,Ciprofloxacin,Clarithromycin,Kanamycin,Streptomycin,Sutezolid
Latest drugs:
Bedaquilline – ATP synthase inhibitor
Delamanid, Pretomanid – Inhibit mycolic acid synthesis
Sutezolid – protein synthesis inhibitor

BCG (Bacillus calmette Guerin) vaccine:

● It is live attenuated vaccine, derived from attenuated Bovine strains. Its

used to prevent disseminated disease & given by a intradermal injection.
● It’s also used to treat Bladder cancer, Leprosy

Non tuberculous mycobacteriums:

● Photochromogens – produce pigment in light
M.Marinum- Fishtank/swimming pool granulomas
● Scotochromogens – produce pigment in light and dark
M.scrofulaceum- produces scrofula in children
● Non photochromogens – Don’t produce pigments
M.avium-intracellulare complex (MAC)- Seen in HIV
M. ulcerans- Buruli ulcer
● Rapid growers- M fortutium, chelonae etc

​Mycobacterium Leprae:​

● They are acid fast bacilli also k/a Hansens bacillus

● Reservior​: human mucosa, skin, nerves.
 ● Transmission​: nasal discharge from an affected untreated patient or
close contact with infected part for long period of time is required for
infection.
● Grows in cooler parts of body like ear lobes, skin, mucous membrane &
peripheral nerves.
● Incubation period for leprosy is 5 yrs d/t generation time (12-13d)

Leprosy is divided into 5 clinical types​:

Tuberculoid, Border line tuberculoid,Border line,Border line lepromatous,

Lepromatous

➢ Symptoms of leprosy are confined to skin & nerves.

➢ M/c nerve involved is Ulnar nerve & Posterior auricular nerve.

Tuberculoid Leprosy ​_ ​Lepromatous leprosy

Strong cell mediated immunity Weak cell mediated immunity

Normal humoral immunity Exxagerated

No of bacilli in tissue are low No of bacilli in tissue are high

Nerve & tissue damage is due to immune sys Due to bacteria.

Few lesions present Multiple lesions

Lepramine test +ve Lepramine test –ve

Hypopigmented, asymmetric. Symmetric, leonine faces

Granulomas are seen Granulomas are absent

As leprosy runs a chronic course allergic reactions occurs throughout its course
k/a Lepra reactions

​Type I lepra reaction (or) reversal reaction:

 ● It’s a type IV hyper sensitivity reaction, seen in border line leprosy which
manifests as inflammation of previous lesions and new skin lesion due to
Th1 predominance

Type II Lepra Reaction:

● It’s a type III hypersensitivity reaction, seen in Lepromatous variety that

usually follows dapsone therapy for lepromatous leprosy patient
● Numerous painful, erythematous papules are seen and here Th2
predominates

Dx:
● Biopsy is taken from edge of the lesion
● On acid fast staining they appear as globi (cigar bundle appearance) present
in foamy macrophages k/a Virchows Lepra/Foamy cells
● It can’t be grown in artificial medium, but can multiply in footpad of mice,
armadillos

Lepramine Test:

● Its type IV hypersensitivity

● Early reaction of Fernandez is + in 48 hrs tells prior exposure
● Late reaction of Mitsuda is + in 21 days indicates intact CMI

Rx:
● Dapsone+ Rifampicin for Tuberculoid leprosy
● Dapsone+ Rifampicin+ Clofazimine for Lepromatous leprosy
● M.indicus.pranii (MIP), heat killed vaccine for leprosy

GRAM –ve Cocci​:

Neisseria:
Grow –ve diplocci that are oxidase +ve
Neisseria Meningitidis ​Neisseria Gonorrhoea

● Lens shaped Kidney shaped

● Capsulated Non-capsulated
● Resp droplets STD
● Ferments both glucose & maltose Only glucose
● Have a vaccine YWCA No vaccine
● B-laclamase prod not seen B-laclamase production is seen

Neisseria Meningitidis (Meningococcus):

Virulence factors:

● Capsular polysaccharide, 5 groups based on capsular polysaccharide into A,

B, C, W135, Y
● Endotoxin ​➔​ DIC, Waterhouse Friedrichsen syndrome
● Produces IgA proteases
● Reservoir: Human Nasopharynx
● Transmission: Respiratory droplets
● Neisseria meningitids, M/C cause Adult Meningitis.
● Risk factors include Complement deficiency esp in C5-C9,Hyposplenism

Meningitis​:

● Fevers, Chills, Rash is m/c distinctive feature

● In fulminate cases there is Waterhouse friedrichsen syndrome
characterized by Septic shock, Large rashes, DIC, Bilateral adrenal
haemorrhages

Lab diagnosis:

● CSF examination:
o 1​st​ part of centrifuge is used for Capsule detection, Biochem analysis (​↑​CSF
pressure, ​↑​protein, ​↓​glucose) Gram staining
o 2​nd​ part for culture on blood and chocolate agar
 ● Latex agglutination test identifies capsuals (serotyping)

Rx​: Ceftriaxone is DOC, Pen G

● Rifampicin, Ciprofloxacin is DOC for prophylaxis.
● Prevention​: is done by YWCA vaccine. There is no vaccine against group B

​ eisseria Gonorrhoea​:
N
● Gram –ve, kidney shaped, non-capsulated, B-lactamase producing
diplococci
● Reservoir​: human genital tract
● Transmission​: is by sexual contact & during birth

Pathogenesis:

● Pili are important for all attachment to mucosal surface. They inhibit
phagocytic uptake
● It also produces IgA proteases
● Porins

Disease Caused:

● Urethritis, Proctitis, Endocervicitis, Salpingitis

● Pelvic inflammatory disease
● Its m/c cause of Septic arthritis
● Its neonates it causes Opthalmia neonatorum

Dx:
● Transport media – Stuarts and Amies media
● Gram staining – 90% sensitive in males and 50% in females
● Culture media:
Acute gonorrhea – Chocolate / Mueller-Hinton agar
Chronic – selective media like Thayer martin, New-york, Martin-lewis media
Rx:​ Cefriaxone is Doc for Gonorrhoea, Spectinomycin (Aminoglycoside) is DOC for
resistant Gonorrhea

GRAM –ve Bacilli

Pseudomonas Aeroginosa:​
● Gram –ve aerobic, oxidase +ve, capsulated rod shaped bacillus
● It’s present in fresh waters, water aerosols and also in raw vegetables and
flowers.
● It produces an endotoxin that causes septicemic shock.
● Pseudomonas exotoxin A acts by inhibiting elongation factor EF II &
inhibition of protein synthesis. The primary organ involved is liver.

​Diseases Caused:

● Eye and Ear infections- corneal ulcers in contact lens users, Swimmer’s ear
and malignant otitis externa
● Respiratory diseases like Ventilator associated pneumonia & Cystic fibrosis
● Shanghai fever – typhoid like illness
● Its catalse +ve so it causes infection in chronic Granulomatous disease
● Skin lesion is in form of Pseudomonas dermatitis, Ecthyma Gongrenosum
with black necrotic (seen in AIDS)
● It’s also causes UTI’s in catheterised patient and Meningitis in Post-op
patients
● Green nail syndrome – paronychia from prolonged submersion in water

Dx:
● It produces a blue green pigment called as pyocyanine and fluroscein on
King’s media
● Selective media- Cetrimide agar

​Rx​-

● Penicillin - Piperacillin, carbenicillin, Ticarcillin

 ● Cephalosporins – Ceftazidime, Cefoperazone
● Carbapenems and Monobactam
● Aminoglycoside – Gentamicin, Tobramycin
● Fluroquinolines – Ciprofloxacin, Levofloxacin

Burkholderia pseudomallei:
● It’s the causative agent of meliodosis that presents with Pulmonary
infections, skin ulcers and lymphadenopathy
● Since it has long latent period its aka “Vietnam time bomb” and is a
potential biowafare medium
● Dx: ​Ashdown medium is used as selective media
● Rx:​ Intensive phase (2 wks) – Ceftazidime (DOC)
● Maintanence phase (12 wks)​ -​ Cotrimoxazole

​ Legionella​:
● Its gram –ve fastidious bacteria, ​Reservoir​: Aquatic sources
● Mode of transmission​: aerosol from contaminated Air conditioners.
Diseased Caused:​ Legionnaires disease and Pontiac fever
● Dx​:
o Culture – Buffered charcoal Yeast agar (BCYE)
o Direct fluorescent antibody (DFA) test
● Rx:​ Azithromycin, Levofloxacin

Francisella tularensis:
● Its gram –ve, intra cellular facultative pathogen
● Reserviors: Rabbits, Deers, rodents
● Spread: Rodents>Tick Bite (Dermacantor)
● Ulceroglandular is MC form other being pulmonary tularemia etc
Dx:
● Francis blood dextrose cysteine agar
● Antibody detection is the mainstay of diagnosis
 ​Rx-​ DOC is Gentamicin

Bordetella Pertussis:
● It produces whooping cough with inspiratory whoop
● Transmission: Respiratory droplets
● Pertussis toxin acts by ​↑​CAMP
● Peculiar feature are lymphocytosis, hypoglycemia & increased histamine
sensitivity

​ hooping Cough:
W

● Its highly contagious disease with IP of 7-10 days and 3 stages

● Catarrhal phase, Paroxysmal phase, Convalescent stage
Dx:
● Best specimen is nasopharyngeal secretions for which alginate swabs are
used (Amies and stuarts are transport media)
● Culture: Regan Lowe or Bordet Genjou media and culture smear shows
thumb-print appearance
● Rx: ​Erythromycin is DOC for treatment and prophylaxis

Brucella:
● It’s zoonotic disease, reservoir being domestic live cattle
● B.melitensis is most pathogenic followed by B.abortus and B.Suis
● They are facultative intracellular so effect RES primarily
● Transmission: Direct contact from infected animal> Ingestion of dairy
● It causes “undulent fever” which is typhoid like illness with more
musculoskeletal symptoms (Malta/Mediterranean fever)

Dx:

● Castaneda method of blood culture

● Acute- Igm detection by standard agglutination test (tube agglutination)
is the gold standard
● Chronic- CFT and ELISA for Ab detection
Rx: ​Rifampacin + Doxycyclin

Campylobacter Jejuni​:
● It’s a micro aerophilic curved rod with polar flagella
● Transmission: Undercooked poultry, Unpasteurized products
● It requires low infectious dose and produces inflammatory diarrhea with
abdominal pain, fever and bloody stools
● HLA-B27: Reactive arthritis and triggers Guillain-Barre syndrome
Dx:
● Gram staining reveals comma shaped rods with seagull wing
appearance
● Dark microscopy shows darting motility
● Transport media- Cary blair media
● Culture – Skirrows’s or Campys agar (Microaerophilic, Thermophilic)
Rx:​ Macrolides are DOC

Helicobacter Pylori:
Its curved gram –ve rod that is associated with gastritis, PUD (most cases),
Adenocarcinoma of stomach, Non-hodgkin’s lymphoma

Dx:

Invasive test:
● Histopathology by Warthin starry silver staining
● Gram stain shows gram – ve rods with seagull’s appearance
● Culture media – Skirrow’s agar, Biochemical tests- Urease and catalase +
● Biopsy urease test
● Non invasive test- Urea breath test
Rx:
1​st​ line- Omeprazole+clarithromycin+Amoxicillin/Metronidazole
2​nd​ line- Omeprazole+Bismuth+Metronidazole+Tetracycline
​Entero bacteraciae
 ● They are gram –ve,non-fastidious, and grow on ordinary media like nutrient
agar
● They are Oxidase –ve, Catalase +ve, reduce nitrate to nitrites

​Entero Bactericae

Lactose fermenters Non- Lactose fermenters

[Pink colories on mac conkey’s agar] [Colorless colonies on mac conkey’s agar]
Ex: Citrobacter Non-motile Motile H2s
Enterobacter [Non H2s producing] producing
Escherichia Ex: Shigella Ex:Proteus
Klebsiella Yersenia Salmonella

E. Coli:
EPEC: I​ t causes infantile diarrhea, Its non-toxigenic & non invasive

EIEC: ​Its non toxogenic but invasive and produces Shigellosis like infection
mediated by virulence marker antigen (VMA)

Dx: Detection of VMA by ELISA, Sereny test, HeLa invasion assay

ETEC: ​Its MCC of traveller’s diarrhea.

● ETEC LT ​↑​ C-AMP, ST ​↑​C-GMP (rabbit ileal loop test+ at 18 & 6 hrs)

EHEC:​
● O157 H7 is MC serotype
● Transmitted by contamined food, undercooked ground beef
● Verotoxin is aka shiga like toxin that acts by inhibiting protein synthesis by
binding to 60s ribosome and require low infectious dose
● HC – bloody diarrhea, abdominal pain, fecal leukocytes but no fever
● HUS- bloody diarrhea, thrombocytopenia, renal failure, but no fever
Dx:
EHEC in contrast to other E.coli doesn’t ferment sorbitol
 Cytotoxixity in Vero cell lines in gold standard

EAEC:
● It cause of persistant diarrhea
● Produces EAST toxin (Entero aggregative heat stable toxin)
● It aggregates in Hep-2 cells in stacked brick fashion so named EAEC

Diseases caused by E.coli:

UTI’s by UPEC (Uropathogenic), Diarrhea (PITHA), Neonatal meningitis,
Visceral abscess, Peritonitis, and Ventilator associated Pneumonia

Rx: ​Ciprofloxacin, Naldixic acid

Klebsiella:
● Klebsiella pneumonia (Friedlander’s bacillus) is Urease + and causes
pneumonia and UTI’s ​Rx- ​Gentamicin, Piperacillin
● K.granulomatis (Calymmatobacterium granulomatis) causes Granuloma
inguinale/venerum/Donovanosis which presents with painless,beefy-red
ulcer ​Rx- ​DOC is Azithromycin, Levofloxacin

Shigella:
● They are gram –ve, oxidase –ve rods
● MC Shigella worldwide is by Shigella sonnei (late lactose fermenter)
● M/C Shigellosis in India is Shigella Flexneri
● Most Severe Shigellosis is caused by Shigella Dysentery type 1.

Pathogenesis:

● It invades through M cells and requires low infectious dose

● Shiga toxin is an exotoxin produced by S.Dysenteriae type 1. It acts by
proten synthesis inhibition by binding to 60s ribosome, S.Flexneri produces
and enterotoxin k/a ShET 1&2

Complications:
 ● HUS and HC, In HLA B-27 it causes reactive arthritis
● Metabolic complications like hypoglycemia, Ekiri synd (toxic
encephalopathy)
● Intestinal – toxic megacolon, perforations
Dx:
Culture media (same for Shigella and Salmonella) are selective media
like DCA (deoxycholate citrate agar), XLD, SS agar
Rx: ​Ciprofloxacin is DOC alt is Ceftriaxone, Azithromycin

Salmonella:
● Typhoidal Salmonella are is S.typhi and S.paratyphi
● Based on O Ag Salmonella are classified into 67 serogroups
● Based on H Ag each serogroup is divided into >2500 serotypes
● It spreads through feco-oral route, requires high infectious does and invade
through M cells and Vi Ag plays role in virulence
● Risk factor is ​↓​ gastric acid
Enteric Fever ​presents with Step-ladder pattern, Rose spots, abdominal
pain, vomitting, and later with GI bleeding and intestinal perforations
Dx:
● 1​st​ week – Culture of blood, bone marrow, duodenal aspirate by
Castaneda’s method, if patient is on antibiotics B.M aspirate is
preffered
● 2​nd​ week- Widal test
● 3​rd​ week- Widal test and Stool culture if patient is on antibiotics
(DCA,XLD,SS agar)
● 4​th​ week- Stool and Urine culture
Widal test: its investigation of choice in 2​nd​ and 3​rd​ weeks
o Ag is less immunogenic (O agglutinin titer >100) forms granular
chalky clumps
o H Ag is more immunogenic (H agglutinin titer>200) forms fluffy
cotton-wool clumps
Rx: ​Ciprofloxacin, Ceftriaxone
 Vaccines – ​TAB (killed), Vi polysaccharide,Ty21a (oral)

Yersinia pestis:
● It causes gram –ve zoonotic infection called Plague
● Reservoir: Rodents
Transmission:
● MC through bite of infected rat flea i.e Xenopsylla.Cheopis- north India
from Sep-May, X.astia- south India throughout the year
● Direct contact with tissue of infected animal, Droplet inhalation from
Pneumonic plague, bite of human flea (Pulex irritans)
● Cheopis index>1 indicated Plague outbreak likely to occur

Bubonic Plague​:

● MC plague characterized by regional bubos (MC inguinal LN)

● No person to person transmission as bacilli are blocked in buboes

Pneumonic Plague​:

● It spreads from inhalation of bacilli from infected person/animals

● Presents with resp symptoms like cough,chest pain and is highly contagious
& fatal type of plague so Aerosolised form is potential biowarfare agent

Septicemic Plague: ​secondary to other plagues leading to “Black Death”

Dx:

● Wayson/Methylene blue stain demonstrate bipolar staining

● On blood agar forms Dark Brown colonies
● On nutrient broth with Oil/Ghee shows Stalactite growth

Rx: ​Doc is Gentamicin​, ​Prophylaxis – DOC Tetracyclin/Doxycyline

Yersiniosis:
 ● Its caused by Y.enterocolitica (MC) and Y.pseudotuberculosis that
manifests as self limiting gastroenteritis with complication
Pseudoappendicitis
● Superantigen of Y.pseudotuberculosis causes IZUMI fever in japan which
is linked to pathogenesis of Kawasaki disease

Proteus:
● P.mirablis, P.vulgaris are lactose non-fermenters, H2S and Urease
producing pleomorphic gram -ve rods
● It causes UTI with alkaline urine which precipitates to form struvite
stones
● P.morgani produces histadine​➔​histamine​➔​scromboid fish poisoning
● Produces swarming motility and fishy odor on media
● Non-motile strains i.e Ox strain (2,19) of P.Vulgaris and Ox K strain of P.
Mirablis forms basis of Weil-Felix reaction

Gardnarella:
● Its Gram –ve, pleomorphic rod causes Bacterial vaginosis (other
agents-Mobilincus, Mycoplasma hominis etc)
Ansel’s criteria for Dx:
● White-grey fluid discharge from the vagina
● Vaginal discharge pH >4.5
● Whiff Test: Fishy odor by addition of 10% KOH to vaginal sample
● Clue cells- vaginal epithelial cells coated with bacilli
Rx: ​Metronidazole, Secnidazole

Vibrio Cholera:
● It’s a halophilic vibrio that is classified into >200 serogroups based on
somatic O Ag. O1 serogroup has 2 biotypes Classical and Eltor and 3
Serotypes namely Ogawa, Inaba and Hikojima

Cholera:
 ● Transmission is by feco-oral route and is toxin mediated. It requires high
infectious dose with IP of 1-2 days
● Presents with sudden onset of painless non-inflammatory diarrhea with
rice watery stools and inoffensive odor
● ‘O’ blood group individuals are more susceptible for cholera

Dx:

● Transport media – Cary Blair or VR media

● Gram staining shows comma shaped rods with darting/shooting star
motility
● Culture media- Alkaline bile salt agar (BSA), TCBS
● Biochem reaction – Cholera red reaction (Indole &Nitrate test +)

Rx:

● Doc for adults – Doxycycline (if resistant – ciprofloxacin)

● Doc for children – Cotrimoxazole, Pregnant- Furazolidone/Azithromycin
● Doc for prophylaxis – Tetracycline
Oral cholera vaccines (OCV- killed and live attenuated) are used

​Halophilic vibrio​:

Vibrio para hemolyticus:​ causes gastroenteritis after eating seafood (oysters).

It shows bipolar staining and Kanagawa phenomenon (Beta hemolysis on
Wagatsuma agar)

Pasturella multocida:
● Transmission is by cat/dog bite
● It produces lymphadenitis and respiratory infection
● It’s capsulated and produces endotoxin.
Rx:​ Penicillin G is DOC

Rat bite fever:

Streptobacillary rat bite fever/Haverhill fever/Erythema arthriticum: Its caused by
Streptobacillus moniliformis, a non-motile pleomorphic gram –ve rod

Spirillary rat bite fever/Soduku: Its caused by Spirillum minus a spiral gram –ve

C/F: Fever, rashes, arthritis, lymphadenopathy (spirillum)

Dx: Spirillum can’t be cultured on artificial media Rx- Penicillin

Bartonella:​
● B.henslae- cat scratch fever and bacillary angiomatosis in AIDS patients
● B.quintana- Trench fever
● B.bacilliformis – Carrion’s disease or Oroyo fever
Rx: Azithromycin, Doxycycline

Hacek Group:

They are gram –ve, fastidious, commensals of mouth so they cause infections
in the mouth and bacterial endocarditis
● H -Haemophillus (aphrophilus, paraphrophilus, parainfluenzae)
● A – Aggregatibacter (actinobacillus) – MC member
● C- Cardiobacterium hominis
● E- Eikennella corrodens (corroded colonies on blood agar)
● K –Kingella kingae
Rx​: Ceftriaxone is DOC except Eikenella- Ampicillin

Haemophilus Influenzae:​
● They are aka Pfeiffer’s bacilli which are blood loving Gram –ve bacilli that
require accessory growth factors present in blood i.e Factor X(hemin)
present freely in blood and Factor V(NAD) present inside the RBC
● Based on capsular polysachharide 6 serotypes (a-f) are identified
● Serotype b (Hib) is most virulent and has a unique polyribosylrubitol (PRP)
capsule which is highly immunogenic used for vaccatination
● It produces IgA protease & helps in colonizing in the mucosa
Diseases:
 ● Meningitis, Epiglottitis (MCC) & Lobar pneumonia, otitis media,
sinusitis in children
● Exacerbation (pneumonia) in COPD, Sinusitis in adults

​Dx:

● Chocolate agar, Blood agar with Satellism

● Quellung test, Latex particle agglutination test is used for capsule
● Disk test for factor X and V

Rx:

● Ceftriaxone is DOC for invasive infections from Hib

● Non-typeable strains – DOC is Levofloxacin /Azithromycin
Prophylaxis is by Hib conjugate vaccine: as capsule is poorly immunogenic
in children its combined with a protein or adjuvants like DT/DT

H. Ducreyi:
● It produces chancroid/soft sore, which is a bleeding genital ulcer that is
extremely painful transmitted by STD
​Rx:​ DOC is Azithromycin (1gm)

H.aegypticus:
● Its also k/a Koch’s-Week bacilli
● It causes Brazilian purpuric fever and Pink eye syndrome (Egyptian
opthalmia)

Treponema Pallidum:
Primary syphilis​:

● It develops after IP of 10-90 days producing Primary/Hard chancre which is

single painless indurated ulcer
● Dx: Most sensitive – Western blot, EIA>RPR>FTA-ABS

Secondary syphilis​:
● Develops after 1-2 months after healing of primary lesion
● Copper colored rash with involvement of palms & soles
● There is Aloplecia, Condylomata lata, generalized lymphadenopathy
● Dx: All tests equally sensitive (100%)

Latent syphilis:

● + serology without clinical manifestations

● Dx: Most sensitive – all treponemal tests

​Tertiary/Late Syphilis​:

● Presence of syphilitic granulomas called `Gummas’

● Dx: Most sensitive – FTA-ABS, TPHA

​Quaternary syphilis: ​CVS and CNS involvement

​Congenital syphilis​:

● It can cause keratitis, 8​th​ nerve damage & Hutchinson’s teeth, Saddle nose,
Saber shins, Bilateral knee effusions (Clutton’s joints)
● Early and common manifestation being Rhinitis [Snuffles] at <2yrs age
● Dx: Igm FTA-ABS/ELISA
● VDRL (IgG)- titre rises in 3 months (falls if maternal transfer)
​Dx:
Dark field microscopy- slender spirochetes with corkscrew motility seen

​Serological diagnosis​:

​Non- treponemal/Non-specific /Standard tests for syphilis (STS):

● Reagin Abs are detected by using cardiolipin Ag found in cow’s heart

● VDRL, RPR, TRUST (toluidine red unheated serum test) Kahn’s (Tube
flocculation test), Wasserman test (CFT)

Specific/treponemal test:

● Specific Abs are detected using T.pallidum antigens

 ● FTA-ABS (fluorescent treponemal ab absorption test) uses killed
treponemes
● Western blot, Enzyme immunoassay (EIA), TPHA (T.P hemagglutination
test) uses antigenic extract of T.pallidum
● Culture- they can’t grow on artificial media so maintained in rabbit’s testes
​Rx:
● Benzathine Penicillin G is DOC for all stages except Late syphilis where
aqueous pen G is more preffered. Alternative is Tetracycline.
Jarisch-Herxheimer reaction may occur d/t penicillins

T. Pertenue – causes Yaws

T. carateum – causes Pinta

Borellia:
● It’s a spirochete
● Borellia recurrentis – Relapsing fever
● Borellia Vincentii – Vincent’s angina
● Borellia burgdoferi- Lyme’s disease.
Lyme’s disease​:
● Transmission- Ixodes ricinus
● Initial symp is erythema migrans followed by AV block or joint pain. Later in
the disease there is arthritis and CNS involvement in the form of
encephalopathy, meningitis or Bells Palsy
Dx​: S​ ero diagnosis by immunofluroscence & ELISA, western blot
Rx:​ DOC is Doxycyclin except CNS and AV block for which Ceftriaxone is DOC

Leptospira:
● Reservoir: Dogs, cattle, pigs
● Transmission​:​ contact with animal urine directly or indirectly
● Leptospirosis has 2 distinct forms i.e Mild anicteric febrile illness and Weil’s
disease (Hepatorenal- hemorrhagic syndrome) which is fulminant
Dx:
 ● On dark field microscopy, spirochete with terminal hooks is seen
● Culture media- EMJH medium, Korthof’s media
● Microscopic agglutination test (MAT) is gold standard
Rx:​ Penicillin G (severe cases) or Doxycyclin (milder cases)

Characteristic Chlamydia Rickettsia Mycoplasma

1. Obligate intra Yes Yes No
cellularity

2. Production of No Limited Normal

ATP

3. Peptidoglycan in Modified Normal No

cell wall

Rickettsia:
● It’s an aerobic gram –ve bacilli that are obligate intra cellular parasite.

Bacteria Diseases Vector

R. Rickettsia Rocky mountain Ticks

spotted fever

R. Atari Rickettsial pox Mite

R. Prowazaki Epidemic typhus Human louse

R. typhi Endemic typhus Fleas

R.tsutsugamushi Scrub typhus Mites

Coxiella burnetti Q-fever Air borne

 Rochalimara Trench fever Louse

Ehrlichiar Ehrlichiosis Tick

R. Conorri Indian tick typhus Ticks

Rocky mountain Spotted fever:

● R.ricketsii is spread by Dermacantor a hard tick.
● Its characterized by high-grade fever, headache, petechial rash on palms and
soles then spreading to trunk and face
Dx:
● Weil-felix reaction is of no value or –ve in a fever Q-fever, trench fever &
Rickettsial pox ​Rx​: Doxycyclin

Scrub typhus:
● Its caused by Orientia tsutsugamushi that presents with eschar,
lymphadenopathy and rash
● Vector – Leptotrombium deliensis in India. Larval stage (chiggers) of
this mite is feeds on human so disease is also k/a chigerrosis
● Dx: Weil Felix test (​↑​Ox K titres)

Coxiella Burnetti [Q-fever]:

● Reservoir: domestic stalk.
● Transmission: inhalation of aerosols from amniotic fluid or placental tissue.
● Presents with fever, pneumonia, hepatitis, endocarditis
● Diagnosis is by serology, Weil– Felix test –ve
Rx​: Doxycyclin

Chlamydia:
● Its obligate intracellular bacteria, cannot be stained by gram stain
● Can’t produce its own ATP so k/a Energy parasite
● It has modified peptidoglycan layer lacking muramic acid
 ● Chlamydia occurs in 2 forms
Elementary body: Extracellular, infective form
Reticulate body: Intracellular, replicating form
● C.trachomatis-Trachoma, Genital chlamydiasis, LGV (Frie test)
● Chlamydia psittaci- atypical pneumonia with parrots, poultry
● C.pneumoniae- CAP associated with atherosclerosis and asthma
Dx: ​Nucleic acid amplification test (NAATs) i.e PCR is gold standard
Rx:​ Doc is Azithromycin (1gm), Doxycyclin is alternative

Mycoplasma:
● It’s the smallest free-living bacteria
● It lacks cell wall, has sterol in its membrane
● Mycoplasma pneumonia is MCC of atypical pneumonia in adults

Diagnosis:

● Culture: Eaton’s agar (has cholesterol), PPLO agar

● Forms fried egg colonies
● PCR is most sensitive whereas culture is most specific
● Heterophile antibody
o Cold agglutination test- detects Mycoplasma Abs by using human O
rbc Ag
o Streptococcus MG test –Streptococcus MG Ag is used
● Rx​: Azithromycin

Mycology
● Study of fungi is k/a mycology.
● All fungal spores are reproductive.
● Fungi are eukaryotes with 80s ribosomes.
● Cell wall consists of Chitin, mannan & other polysaccharides.
● Cell membrane contains ergosterol.
 ● Some fungi are useful to man such as edible mushrooms. Certain yeasts are
used in fermentation and some fungi in elaborating antibiotics (Penicillium).

Classification of fungi:
Based on morphology:

➢ Yeast ​is single celled. Ex: Cryptococcus neoformans, Saccharomyces.

➢ Yeast like​ contains pseudohyphae. Ex: Candida albicans.
➢ Moulds​ have branching filaments called hyphae. Ex: Dermatophytes,
Aspergillus, Rhizopus, Mucor, and Penicillium.
➢ Dimorphic fungi​ exist in 2 forms I,e Yeast in tissues [i.e at 37® C] & moulds
in soil & culture [i.e at 25®C]
Ex: Histoplasma capsulatum, Sporothrix schenckii, Blastomyces
dermatitidis, Coccidiodis immitis, Paracoccidiodis brasiliensis.

Based on sex spores:

➢ Zygomycetes-​ zygospores Ex: Zygomycosis agents

➢ Ascomycetes-​ ascospores Ex: Aspergillus
➢ Basidiomycetes​- basidiospores Ex: Cryptococcus
➢ Deuteromycetes/ Fungi imperfecti-​ most medically imp fungi

Asexual spores can be ​vegetative spores ​or ​aerial spores.

➢ Vegetative spores- Blastospores, Arthrospores, Chlamydospores

➢ Aerial spores- Conidiospores, Microconidia, Macroconidia,
Sporangiospores

​D​x:
● Direct examination​:
● 10% KOH wet mount,Gram stain,India Ink preparation, Wood’s lamp
exam
● Culture:
● Sabouraud’s dextrose Agar (SDA)
 ● Brain heart infusion (BHI)

Fungal Infections
❖ Superficial Fungal Infections
Pityriasis versicolor/Tinea Versicolor:

● Caused by ​Malassezia furfur (Pityrosporum oribiculare)

● Presents with hypogigmented spots on back, chest, abdomen & neck
● Its also responsible for Seborrheic dermatitis (dandruff)
● KOH staining shows characteristic sphegetti & meat balls/ banana &
grape appearance.
● Diagnosis is done by fluroscence under wood lamp
● It involves only dead layers of skin (keratinized layer) and is an
endogenous infection
R​x:​ Topical Selinum sulphide/ketoconazole shampoo
❖ Cutaneous fungal infections
➢ It can be in the form of dermatophytes or cutaneous candidiasis.

Dermatophytes:
● Dermatophytoses are also k/a Tinea or Ring Worm.
● Itching is the m/c symptom of Tinea infection.
● They are of 3 types –Trichophyton, Microsporum, Epidermophyton.

​Epidermophyton​ ​Trichophyton​ ​Microsporum

Tissue inv: Skin & Nails. Skin, Hair, Nails. Skin & Hair.

On SDA: No microconidia Micro > Macro Micro < Macro

Shape (macroconidia): Pear shaped Pencil shape Spindle shape

 ● Tinea capitis​ ​is the ringworm infection of scalp. Kerion, Favus, Ectothrix
and Endothrix are different forms

● Tinea barbae​/​barber’s itch​ is seen in beard area,​Tinea corporis​ is the

infection of the non-hairy skin of the body,​Tinea cruis​ involves groin
area,​Tinea pedis​ is infection around foot,​Tinea unguam​ is infection
around nail
Dermathophytid reaction is allergic reaction to circulating fungal antigen.

​D​x:

▪ Wood lamp examination with UV light of infected hair shows fluorescence.

▪ KOH mounting shows hyphae & arthroconidia.
▪ Culture is by Sabouraud’s Dextrose Agar
R​x:
Oral Terbinfine/ItraconazoleisDOC, Oral Griseofluvin is alternative

❖ Sub-Cutaneous Infections
Sporotrichosis:
● Sporothrix schenckii​ causes Sporotrichosis aka Rose Garden’s Disease that
presents with ulcers along the lymphatics and LN enlargement
● Rare forms are osteoarticular or pulmonary type
● Its prevalent in Himalayan hilly areas
D​x:
● On H& E shows Cigar shaped asteroid bodies
● Skin test shows type IV HSN to sporotrichin Ag
R​x:
● Intraconazole (cutaneous sporotrichosis)
● Amphoteracin B (extra cutaneous)

Mycetoma:
 ● It is a chronic granulomatous infection of the subcutaneous tissue, usually
affects foot and rarely the other parts of body
● It is of 2 types- Bacterial & Fungal
● This disease begins as a subcutaneous swelling usually of foot that
produces characteristic abscess. The abscess bursts forming multiple
sinuses discharge pus that contains granules
● A condition resembling mycetoma is k/a botryomycosis
D​x​:
● Diagnosis is made from examination of granules
● Eumycotic mycetoma-black/white granules with hyphae >2μm seen
● Actinomycotic mycetoma- gram +ve filamentous <2μm bacteria are seen
R​x:
● Actinomycotic mycetoma- Amikacin+ Cotrimoxazole
● Eumycotic mycetoma- Itraconazole/Amp B for 2 years

Chromoblastomycosis:
● It’s caused by ​Dematiaceae gorup (dark pigmented fungi)
● It causes Verrucous type lesions most commonly
D​x:
● On H&E staining, they characteristically show Sclerotic bodies/Medlar
bodies/Muriform cells
R​x: ​Surgery followed by Itraconazole
Rhinosporidiosis:
● It is caused by ​Rhinosporidium seeberi​ (fungus or protist)
● It is a chronic granulomatous disease characterized by formation of friable
polpys on the nose k/a strawberry polyps.
● The infection is seen mainly seen on coastal areas of India & Sri Lanka and
is acquired by swimming or frequent contact with stagnant water or
aquatic life
 D​x:​The fungus has not been cultivated
R​x: ​Surgical removal of polyps

❖ Deep Fungal Infections

​Histoplasmosis (Darling’s disease):

● It is caused by ​Histoplasma capsulatum,​a dimorphic fungus
● Infection is acquired from inhalation of spores from soil/dust contaminated
with birds/bats droppings
● Pulmonary histoplasmosis is the mc form, disseminated in HIV
● Its endemic in USA(Ohio and Mississippi river) and frequently in India from
West Bengal near Ganga river

​D​x:
● Tissue samples shows yeast forms that typically show narrow based
budding
● Histoplasmin skin test

​R​x​: Amp B is the DOC, alternative is Itraconazole

Coccidiomycosis:

● It is caused by ​Coccidiodes immitis​ a dimorphic fungus

● Its aka Desert rheumatism, Valley fever, California fever as its endemic in
California, Arizona, Texas, New Mexico, Northern Mexico
● Pulmonary form, Erythema nodosum, arthritis is the presentation
● D​x:
● Biopsy or culture on SDA shows yeast form, which is a thick double walled
spherule, filled with endospores
● Coccidiodin skin test
R​x​: Itraconazole
Blastomycosis:
● It is caused by ​Blastomyces dermatitidis ​a​ d
​ imorphic fungus
● It’s aka North American Blastomycosis/Chicago/Gilchrist’s disease

D​x: ​Broad based buddung with figure of 8 appearance

R​x​: ​Amphoteracin B
Paracoccidiodomycosis:
● It is caused by ​Paracoccidiodes brasiliensis a​ dimorphic fungus
● It is also k/a South American Blastomycosis
D​x:
● It produces buds with Captain/Pilot wheel/Mickey mouse appearance
R​x: ​Amphoteracin B.

❖ Oppurtunistic infections:

Candidiasis:
● M/c agent responsible is ​candida albicans.
● Candida albicans forms pseudo-hyphae
● Its normal inhabitant of skin, GI tract, oral & vaginal cavities
● Predisposing factors: ​Diabetes, AIDS, Pregnancy, Infants & elderly,
prolonged administration of antibiotics, patients on immunosuppressive
drugs
Mucocutaneous lesions:​ ​Oral thrush, Vulvovaginitis, Balanitis,
Conjunctivitis, Keratitis,Esophageal candidiasis
Systemic candidiasis:​ ​UTI, Intestinal candidiasis, pulmonary candidiasis,
endocarditis, meningitits, osteomyelitis
​D​x:
● On KOH mount shows pseudohyphae & budding yeast.
● Tests to differentiate ​C.albicans ​from other species are:
 o Germ tube test/Reynold’s Braude phenomenon: formation of germ
tubes when incubated in human serum (at 37®)
R​x​: Esophageal & Vulvovaginal candidiasis- Fluconazole
Disseminated- Amphoteracin B is DOC

Invasive – Amphoteracin B + Enfungumab (HSP 90)

Cryptococcosis:​
● Its caused by ​C.neoformans, a​ capsulated, urease +ve fungus
● Infection is acquired by contaminated soil from pigeon droppings
● It can cross BBB either directly or carried inside macrophages k/a Trojan
horse
● Pumonary cryptococcosis is the MC form, Meningitis in AIDS
D​x:
● India ink staining (negative staining) for the capsule
● Gram staining show budding yeast
● Latex particle agglutination test detects polysaccharide capsular antigen
from CSF (95% sensitivity)
R​x: ​Amphoteracin B + Flucytosine for Meningitis
Fluconazole is DOC (without CNS involvement)

Pneumocystis jirovesi​ [Pneumocystis carinii pneumonia]:

● It was previously classified as protozoa
​ /t
● It produces pneumonia in HIV patients. It produces ​frothy exudate d
plasma cell response hence aka Plasma cell pneumonia
● D​x: ​Gomori methenamine silver stain shows black colored crushed
pingpong balls appearance
● R​x:​ ​DOC for prevention & treatment is Cotrimoxazole

Aspergillosis:
● Aspergillus fumigatus i​ s the main opportunistic pathogen
 ● It is an opportunistic fungus that shows septate hyphae with dichotomous
branching-45® angle

Types of Aspergillus

​ tomycosis – ​A.niger,​ Keratitis ​– A.fumigatus

● Aflatoxin ​– A.flavus ,O
● Pulmonary aspergillosis is MC form existing as Allergic Broncho pulmonary
aspergillosis [ABPA], Fungus ball/Aspergilloma, Asthma
● Invasive sinusitis, Ocular (Keratitis), Ear (otitis externa) are other forms
R​x:
● Lobe-ectomy for aspergilloma
● Gluco corticoids, Itraconazole for ABPA
● Voriconazole for Invasive Aspergillosis

Zygomycosis/Mucormycosis:
● They are non-septate, filamentous fungi
● Rhizopus, Mucor, and Absidia cause it
● Predisposing conditions are Diabetic ketoacidosis [DKA], Renal disease
● Rhizopus causes zygomycosis & otomycosis
● M/c presentation is Rhinocerebral zygomycosis, followed by pulmonary
zygomycosis seen in leukemic patients
D​x:
● On SDA medium Rhizopus has nodal rhizoids & sporangiophores arise in
groups directly above the rhizoids.
● Absidia also has rhizoids but sporangiphores arise from the aerial mycelium
in between the rhizoids.
● In Mucor, sporangiophores are present but rhizoids are absent