Exam 5 Material - MICR PDF

Dr. K  The Genitourinary Tract and Its Defenses The structures in the genitourinary tract are really two distinct organ systems - urinary tract: removes substances from the blood, regulating The System certain body proces...

Dr. K  The Genitourinary Tract and Its Defenses The structures in the genitourinary tract are really two distinct organ systems - urinary tract: removes substances from the blood, regulating The System certain body processes, and forming urine and transporting it out of the body - genital system: also known as the reproductive system, functions mainly in reproduction  The Urinary System The urinary tract - kidneys: remove metabolic wastes from The blood, acting as a sophisticated filtering The Urinary System Left kidney system - ureters: tubular Right kidney organs extending from (cross-section) each kidney to the bladder - bladder: collapsible Ureters organ that stores urine and empties it into the Bladder urethra - urethra: conduit of Urethra urine to the exterior In males, the urethra is the of the body terminal organ of the reproductive tract In females, the urethra is separate from the vagina Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.  Urinary Tract Defense mechanisms Urine flushing and desquamation - flushing action of urine flowing out of the system - urine flow also encourages desquamation (sloughing) of epithelial cells lining the urinary tract, shedding microbes The Urinary System -Normal flora Urine sterile Contaminated by skin/fecal flora at end of urethra Urethra has normal flora Antibacterial proteins Lysozyme-breaks down peptidoglycan Lactoferrin-binds free iron, inhibits bacterial growth Secretory IgA: specific for previously encountered microorganisms  General terms for Urinary Tract Infections (UTI) The Urinary System § Pyelonephritis- infection of kidneys can lead to sepsis § Cystitis-infection of urinary bladder § Urethritis-inflammation of urethra  Diagnosis Quantitative urine culture on Blood agar and MacConkey agar Quantitative- plate 10 µl (0.01ml) by calibrated loop Number of colonies on the plate X 100 get CFU/ml The Urinary System Calibrated loops 10 µ l  Urine Specimen types CCMS-Clean Catch Mid-Stream The Urinary System Suprapubic aspirate Catheterized specimen  Screening Urine Specimens for bacteria Dipstick method o Leukocyte esterase- enzyme produced by neutrophils The Urinary System - (+) indicates PMNʼs-infection o Nitrites-Result of nitrate reductase (bacterial enzyme) acting on nitrate in urine - (+) indicates presence of some bacteria  Urethritis due to Coliforms 1. E coli Gram-negative rod Possible capsule Bacterial COLIFORM- lactose-fermenting gram-negative rod Coliforms include- E. coli Klebsiella, Enterobacter, Citrobacter all of these can cause UTI’s  Urethritis Disease Inflammatory response Painful urination/burning, cloudy/pink Bacterial (bloody) urine Ascending infection, can lead to a) Cystitis b) Nephritis  Epidemiology of E. coli UTI Most common cause 85% -7 million E. coli /yr. Community-acquired Bacterial Fecal contamination from your self- ENDOGENOUS Nosocomial infections 90,000/yr -Catheterization (90%)  Diagnosis of E. coli UTI Standard urine culture -Gram-negative (grows on MacConkey and blood) -Lactose-fermenter (magenta on MacConkey agar) Bacterial  Treatment of E. coli UTI Antibiotic resistance common Susceptibilities important Prevention Bacterial Good sanitary technique Especially women  2. Urethritis due to Enterococci Enterococcus Opportunistic pathogen 2nd most common cause Bacterial - 10% of all UTI - 16% nosocomial UTI  Diagnosis of UTI due to Enterococci Culture on blood agar & MacConkey agar Plate 10µl & count Growth on the MacConkey plate?? Gamma-hemolytic, Catalase - Lancefield group D Bacterial Enterococci do not produce nitrate reductase - dipstick false-negative Treatment of Enterococci UTI Naturally antibiotic Resistant Serious infections treat with combination of antibiotics Prevention Cleanliness  3. Other species causing Urethritis Klebsiella sp. Staphylococcus aureus Other Staphylococcus Bacterial Proteus sp. Enterobacter sp. Pseudomonas sp.  4. Cystitis 95 % E. coli Symptoms in females Dysuria- painful urgent urination Bacterial Epidemiology Primarily women -Female UTI 8X rate of men 25 WBC per low power field (40X) on Gram stain  Diseases of LRT The Lower Respiratory System Pleuritis 1) Pain is main symptom 2) Smooth pleural lining gets inflamed and rough, rubs together, can hear “rubbing” with stethoscope Pneumonia 1) Infection of the lungs  1. Whooping cough Bordetella pertussis Small Gram-neg. coccobacillus Capsule – on virulent strain Bacterial Respiratory droplet spread Outbreaks in schools & on college campuses  Whooping Cough Disease Stages 1) Catarrhal stage = cold-like/fever 2) Paroxysmal stage = cough-whoop Bacterial 3) Convalescent stage = lasts for months Bronchii infection in adults (bronchitis) Immunized less severe symptoms  Pertussis Virulence Factors Toxins A-B toxin a) Pertussis toxin-systemic symptoms a) Tracheal toxin- damages ciliary cells Bacterial Adhesin b) Filamentous hemagglutinin attaches to ciliated epithelial cells b) Impedes ciliary action-destroys cells Capsule  Fig. 1: Synergy between pertussis toxin Pertussis toxin(PTX)= AB toxin and filamentous hemagglutinin in binding to ciliated respiratory epithelial cells Bacterial WBC Result: 1) Inhibition of phagocytic killing Result: 1) Stops Mucocilliary escalator and monocyte migration. 2) Allows entry to lower 2) Increase in mucus secretions. respiratory tract  Diagnosis of Pertussis Clinical signs/symptoms § Characteristic Whoop Treatment of Pertussis Culture on specialized media Erythromycin Rapid serological testing - Stops toxin synthesis PCR Prevention Bacterial Vaccine wanes after 5-10 years - Acellular vaccines (DTaP) Immunity after infection-Good DTaP= Diphtheria Tetanus acellular Pertussis  2. Primary pneumonia (Lobar-lung lobes; broncho- alveoli) Streptococcus pneumoniae (Pneumococcal pneumonia) Gram positive diplococci Bacterial Pyogenic coccus (pus-forming) Purulent- full of pus  Primary Pneumonia Disease 1. Acute inflammation-affects bronchi & alveoli 2. Alveoli fill with pus 3. Infection spreads Bacterial 4. Symptoms = high fever, chills, chest pain, rust-colored sputa, difficulty breathing 5. Patient appears very toxic 6. Bacteria invade pleura = pleurisy 7. Bacteria invade blood= sepsis  Diagnosis of S. pneumoniae Gram-positive diplococci Bacterial Culture ü Catalase-negative ü a-hemolytic ü Optichin-sensitive (P disc) Capsule serotypes a) 90 Serotypes  Treatment Virulence Factor Deadly if untreated Capsule Penicillin a) Dense resists phagocytosis Floroquinolones Regional resistance increasing Bacterial Prevention Vaccine- 1) PNEUMOVAX - For elderly = multiple capsule types (23) ØMany illnesses end in pneumonia 2) PCV 13 -For kids = proteins covers 13 pneumococcal serotypes  3. Atypical Pneumonia or Walking Pneumonia 1) Mycoplasma pneumoniae No cell wall Plasma membrane with sterols Doesn’t grow on regular media Sputum culture rules out 1o Bacterial Treatment?  Mycoplasma pneumonia Disease Low-grade fever Non-productive cough Infiltrate is in the tissue, not the alveoli so called interstitial pneumonia Self-limiting but lasts months Bacterial No invasion to blood Epidemiology Sporadic epidemic periods May be 20% of all pneumonias in young adults and small children  3. Atypical Pneumonia or Walking Pneumonia 2) Chlamydophila pneumoniae Chlamydial pneumonia Organism: a) Has infectious cycle Bacterial b) Obligate intracellular parasite Similar to Mycoplasma Very common infection Won’t grow on media  3. Atypical Pneumonia or Walking Pneumonia 3) Legionella pneumophila Gram-negative bacilli Facultative intracellular bacteria - infects macrophages Legionella inside macrophage Much less common form of Bacterial atypical pneumonia Associated with outbreaks only Legionaires Disease Pneumonia (Legionaires disease) Pontiac Fever-fever, muscle aches, cough History = 1976 - American Legion-Philadelphia - 200 sick/29 died  Epidemiology of legionaires Sporadic epidemic periods OUTBREAKS Chlorine resistant Aerosol water sources Found living inside amoebas Bacterial Diagnosis Charcoal yeast extract media Fluorescent Ab DNA Probe Treatment Erythromycin or other macrolides  4. Tuberculosis Bacterial  Mycobacterium tuberculosis intracellular Bacterial Resistant to drying antimicrobials, antiseptics AFB smear  TB Disease Only 10 cells for infection Incubation period can be years Initial inflammation Ø Infected Macrophage Ø Macrophages and Active TB Bacterial lymphocytes infiltrate Tubercle formation Fibroblast Neutrophil Core of the tubercle contains bacilli within macrophages Outer wall contains fibroblasts, lymphocytes, and neutrophils  TB Disease (cont) Latent TB Calcification Reactivation- more inflammation and spread Caseating necrosis Reactivation Bacterial Possible restoration of immune status and calcification Reactivation  Granulomas in the lungs Call Tubercles- pulmonary TB Granuloma cells Which is the most common Tubercle Extrapulmonary or Miliary TB – Infects other organs Caseous Bacterial necrosis – Granulomas in other organs, Epithelioid bone, blood cells – Associated with immuno- compromised patient – This is deadly! Figure 19.10 © John D. Cunningham/Visuals Unlimited  Active Tuberculosis Disease severe symptoms develop: “consumption” -violent coughing -greenish or bloody sputum -low-grade fever -anorexia, weight loss Bacterial -extreme fatigue -night sweats -chest pain  Epidemiology of TB Spread by respiratory droplet 20,000 cases/yr in U.S. 2,000 deaths/yr Bacterial Increasing drug resistance Worldwide epidemics & imported cases Serious problem with AIDS  Diagnosis of TB 1) SCREENING -Tuberculin skin test (TST) or Purified Protein Derivative (PPD) - Induration diameter =measure Bacterial infiltrate - Delayed-type hypersensitivity (Type IV) What can give you a positive PPD or TST? - Active TB - Latent TB (tubercles) - Extrapulmonary TB - BCG vaccine - Past exposure - Cured TB  Diagnosis of TB 1) Screening if symptomatic AFB Smear AFB stain of sputum and look for Acid Fast Bacilli Bacterial Acid Fast organisms are pink/red All other cells (ours and bacteria) are blue  Diagnosis of TB Definitive test for active TB X-ray, CT Scan DNA probe assay, PCR Bacterial Culture and susceptibility 3-6 wks  Treatment of TB Combination of three drugs to combat resistance - Isoniazid, rifampin, pyrazinamide Prolonged course- 6 mo. - Slow-growing intracellular pathogen - Concern- lack of compliance Bacterial Prevention of TB Live attenuated vaccine a) BCG vaccine=Bacille Calmette Guerin (Mycobacterium bovis) b) Used in Europe, Africa U.S. uses surveillance and therapy  Mycobacterial infections in Immunocompromised Can get pneumonia from Non-tuberculous Mycobacteria (NTM) Not TB Not M. leprae (can’t cause lung infection) Bacterial  5. Secondary Pneumonias a. Pneumonia secondary to existing infection Bacterial or viral b. Causative agents Bacterial Staphylococcus aureus Streptococcus pyogenes Pseudomonas aeruginosa Klebsiella pneumoniae Haemophilus influenzae Moraxella catarrhalis  Respiratory Case 1 A 25-year-old medical student develops fever and cough, and chest X-rays show consolidation of the right lower lobe. Routine bacterial sputum culture results are negative showing only small numbers of normal oral flora. Question  Viral Pneumonia Many additional viruses may contribute to pneumonia Virus  Viral Pneumonia 1. Respiratory Syncytial Virus (RSV) Disease Common infection of infants - premature infants at highest risk 1st 18 mo. - 100,000 hospitalized / yr Virus Symptoms- cough, wheezing (bronchial sounds), no fever - Interstitial pneumonia-no accumulation of pus - Babies can’t suck to eat Many additional viruses may contribute to pneumonia  RSV disease (cont) Life-threatening in elderly Most children infected by age 2 Diagnosis by rapid serology Virus High risk treated with immune globulin Therapy with ribavirin (antiviral)  2. Influenza Viral structure Influenza A and B viruses Enveloped virus Hemagglutinin spikes -Clumps RBC Matrix protein -Recognizes and attaches to cells Negative-sense Virus RNA, nucleoprotein Neuraminidase spikes Ion − Helps separate from cell after channel replication Hem agglutinin (H) Neuraminidase These determine subtype (H2N3) (N) 8 RNA Segments Lipid envelope from Host membrane  Influenza Signs and Symptoms: begin in upper respiratory tract, can progress to lower tract Virus headache, chills, dry cough, body aches, fever, stuffy nose, sore throat extreme fatigue secondary infections  Epidemiology of Influenza Major disease outbreaks by Inf. A Inf. B limited locale and milder disease Flu season each year Nov.- March Endemic years Epidemic years Virus Pandemic of 1918-19 unus. lethal may have 100,000 cases 20 million deaths worldwide 50-70,000 deaths/yr US Elderly Death due to secondary infection Epidemics usually originate in Asia Animal – human co-infections Strains recombine- get new strains  Antigenic Shift = Change from H3N2 in 1889 epidemic to H1N1 major genetic recombination 1918-19 Virus (Antigenic Shifts lead to major epidemics)  Origins of Influenza A H RNA caused by genetic shift N RNA Duck influenza virus Human influenza virus Virus H H1N1 example: N reassortment of Avian (H5N1) and older Human influenza virus swine flu genes (H1N1 from 1978) with duck H spike Mix in swine to produce a new novel H1N1 Flu strain  Antigenic Drift – minor mutations so that the subtype remains the same, but more infections occur. – Mutations common RNA viruses Virus lack DNA “proofreading”. – Vaccines less effective over time.  Diagnosis of Influenza Signs and symptoms ELISA for Influenza A or B Virus Treatment of Influenza A Amantidine – inhibits uncoating step - Must be take 48 hr. after symptoms - Reduces symptoms Relenza, Tamiflu-inhibit neuraminidase - Within 30 hrs of infection-shortens duration  Prevention of Influenza Flu vaccine Antigenic mixtures to anticipate the next epidemic- QUADRIVALENT (4 strains) take 1 year to prepare Killed virus (shot) Host response still apparent Vaccine yields anti-H and anti-N antibodies -Good short-term-3 yrs Virus -Complete protection also requires Cell-mediated response Beginning again in 2024-2025, all flu vaccines in the United States will be “trivalent” vaccines, which means they protect against three different flu viruses: an influenza A(H1N1) virus an influenza A(H3N2) virus an influenza B/Victoria virus High-Dose Quadrivalent available for persons over 65  FluView 2023-2024 Virus  3. SARS (Severe Acute Respiratory Syndrome) New coronavirus in China MERS (Middle East Respiratory Syndrome) SARS associated Coronavirus (SARS-CoV) MERS associated Coronavirus (MERS-CoV) Virus  SARS/MERS Disease Incubation 2-7 days High fever, body aches, mild respiratory symptoms Diarrhea 10-20% of cases 2-7 days cough develops Most develop pneumonia/ acute respiratory distress 10-20% Patients require mechanical ventilation Virus  Epidemiology of SARS MERS First reported in Asia first reported in 2012 in Saudi Arabia February 2003 § Spread to UAE, Qatar, Oman, Spread to NA, SA, Europe, Jordan, Kuwait Asia different from any other 2003-8000 cases, 774 deaths coronaviruses that have been found US had 192 cases, no deaths in people Virus Travelers from outside US 2 cases in US Transmission by respiratory Travelers from outside US droplets Requires close person-to- Transmission by respiratory droplets person contact Requires close person-to-person contact since 2004, there have not been any known cases of At the end of January 2020, a total of SARS reported anywhere in 2519 laboratory-confirmed cases the world 866 associated deaths (case-fatality rate: 34.3%) were reported globally.  COVID-19 Virus The virus: SARS CoV-2 The location: Everywhere (Pandemic)  COVID-19 § The SARS-CoV-2 virus is a betacoronavirus, like MERS-CoV and SARS-CoV. § It is an enveloped icosahedral virus. § All three of these viruses have their origins in bats? Don’t know for sure. § The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir. Also an earlier pocket from Europe from early 2019 Virus What we know about enveloped viruses They are easy to inactivate They do not last long on surfaces  COVID-19 Virus Diagnosis a) PCR for viral RNA (DNA) b) ELISA for Ab Treatment a) Supportive therapy (10-20% Patients require mechanical ventilation) b) Antiviral remdesivir c) monoclonal antibody therapy bamlanivimab Prevention a) Avoid close contact b) Quarantine/travel restrictions c) Don’t touch your face d) Hand washing  The Vaccine Virus  Mycotic infections Infections caused by fungus Eukaryotic Problem for immune compromised Fungus  1. Histoplasmosis Cause: Histoplasma capsulatum Yeast-like during infections (dimorphic) Infects macrophages (survives and multiplies) Fungus Infection is similar to TB-lesions Figure 24.17 In human tissue Bat guano  Histoplasmosis Disease Lung infection first Involves multi-system disease later (1% of cases) Fungus  Epidemiology of Histoplasmosis Farmers, landscapers, construction workers Spread from the droppings of birds and bats Humans inhale spores Fungus AIDS and immune compromised at high risk  Diagnosis of Histoplasmosis Clinical signs/symptoms Serological tests (ELISA) Fungus DNA probe Treatment-Antifungals  2. Blastomycosis a. Blastomyces dermatitidis Dimorphic fungus Yeast form in infection Fungus Mycelial form Yeast form b. Disease Lung disease initially Spreads to rest of the body Causes skin ulcers  3. Coccidiomycosis Coccidioides immitis Dimorphic fungus Disease Fungus Most infections inapparent Cough, weight loss, chest pain, low fever TB – like (tissue spherules)  Epidemiology of Coccidiomycosis Southwest U.S Soil-filaments-arthrospores- wind Fungus Driving through pandemic area during dust storm AIDS persons in pandemic areas  4. Aspergillosis Aspergillus flavus Producing reproductive spores Fungus Grows in grain Produces aflatoxins a)Carcinogens  Aspergillosis disease Occupational disease Farmers Lung infections Fungus Immunosuppressed (AIDS) 1) Aspergilloma 2) Disseminated infections Treatment Amphotericin B  5. Pneumocystis Pneumonia Pneumocystis jirovecii Classified as a fungus, yeast-like Forms cysts like parasites Fungus found in healthy human lungs Pneumonia occurs in infected infants & immunosuppressed individuals (AIDS)  Pneumocystis Disease Inapparent infection in most Disease in AIDS patients and Immunocompromised Diagnosis Fungus cysts in sputum Treatment Trimethoprim/Sulfamethoxizole anti-fungal  6. Opportunistic Mycotic Infections Infection caused by everyday molds and fungi Usually only a problem for immune compromised (AIDS) Fungus  Nosocomial infections Rhizopus Bread mold Mucor Bathroom mold Fungus Human petri plate Immunosuppressed AIDS There is so little immunity that anything will grow  Mycotic infection overview Disease Organism Reservior At risk Epidemiology Histoplasmosis Histoplasma BATS and birds Cavers/ *IC/ AIDS Pneumonia-TB-like Farmers/landscapers Macrophages Blastomycosis Blastomyces Arid Soil/dust *IC/ AIDS Pneumonia Skin ulcers Coccidiomycosis Coccidioides Arid Soil/dust *IC/ AIDS Pneumonia Fungus Skin infection Aspergillosis Aspergillis Crop mold dust *IC/ AIDS/ Farmers Pneumonia Aflatoxin - cancer Pneumocystis Pneumonia Pneumocystis Soil AIDS Pneumonia Opportunistic Rhizopus Everyday items AIDS Pneumonia Mucor Death *Immune Compromised Respiratory case 2 The patient is a 70-year-old female who 1 year previously was diagnosed with multiple myeloma. She had been treated with 5 cycles of immunosuppressive drugs, including prednisone, with the last cycle completed 6 weeks ago. The patient presented with a 2-day history of dyspnea (shortness of breath) and a cough productive of white phlegm. She denied hemoptysis (coughing up blood), night sweats, fever, chills, abdominal pain, nausea, vomiting, or chest pain.  On physical examination, she had a fever of 38.8oC, pulse of 120/min, and a respiratory rate of 20/min. Chest auscultation was significant for bilateral crackles with respiratory wheezes. Chest X-ray showed bilateral diffuse pulmonary infiltrates with effusion. White blood cell count was 1,700 cells/µl. Two sets of blood cultures were obtained, and she was begun on cefotaxime and clindamycin intravenously. Question  Respiratory review for Exam 5 Know barriers to infection Definitions Normal flora of the LRT Purulent Quality Sputum Numbers Bacterial causes of LRT Gram stain result 1. Boretella pertussis 2. Streptococcus pneumoniae Diseases caused 3. Atypical or walking pneumonia Epidemiology 1) Mycoplasma 2) Chamydophila Virulence factors & toxins 3) Legionella Key differentiating characteristics 4. Mycobacterium tuberculosis  Viral causes of LRT disease Definitions Terms 1. RSV Antigenic drift Diseases caused 2. Influenza Antigenic shift 3. SARS/ MERS/ COVID Epidemiology Key differentiating characteristics Fungal causes of LRT disease (know mycotic overview table) Diseases caused Epidemiology Key differentiating characteristics Cases