Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

BS RADIOLOGIC TECHNOLOGY

MODULE

Prepared by:

JEMUEL FRED O. CAPOQUIAN, RRT

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Over View

As a third year BSRT student, soon you will be in hospitals for your
internship. This subject is one of the requirements before you can proceed to clinical
setup. Studying radiographic pathology was chosen for many reasons and this
module will help you to establish knowledge on how pathology is consequential.

During your previous years as a student, you have studied anatomy

and physiology. Without basic knowledge in anatomy and physiology, it would be
impossible to understand pathology. In this subject you will learn many types of
diseases that may develop or may acquire by our body. But the most important thing
about considering pathology as radiologic technologist is to provide good quality
radiographs as doctors allow them to better see tissues architectures and
abnormalities, and you should be aware of that.

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Learning Outcomes

At the end of this course, student will recognize common pathologic conditions
and apply appropriate examination procedure and technique for best presentation of
body part of interest. Student will

 review the human body as a structural and functional unit;

 explain the significance of surface anatomy and identify locations of different
radiographic structures;
 define basic terms related to pathology;
 discuss the classifications of trauma;
 describe the major categories of pathologic basis of disease formation as to
its cause, biochemical, and tissue change and result;
 describe the basic manifestations of pathological conditions and their
relevance to radiologic procedures;
 differentiate and describe various pathological conditions of the different body
systems as to etiology, inflammation, neoplasm, and trauma or injury;
 identify imaging procedures and interventional techniques appropriate for
diseases common to each body system;
 identify common pathological conditions affecting the organ system as
presented/viewed on the radiograph;
 describe the radiographic appearance of diseases.

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Lesson Review of Human Body

1

Welcome to the study that will you give you the

means to learn the fundamentals of radiographic
pathology (study of diseases). Since radiography is one
of the primary methods of diagnosing disease, studying
certain pathologies will provide you knowledge in clinical
setting. Before that, you need to review the basic of
human body.

Learning objectives
On completion of this lesson, you should be able to:
 Describe the levels of structural components within the body
 State the boundaries of the body cavities
 Define and understand directional terms and body planes.

Abstraction
The human body
is rather like a highly
technical and
sophisticated machine.
It operates as a single
entity, but is made up of
a number of systems
that work
interdependently. Each
system is associated
with a specific function
that is normally
essential for the well-
being of the individual.
Should one system fail,
the consequences can
Figure 1.1 levels of structural organization complexity

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extend to others, and may greatly reduce the ability of the body to function normally.
Within the body are different levels of structural organization and complexity.
The most fundamental of these is chemical. Atoms combine to form molecules, of
which there is a vast range in the body.

I – STRUCTURAL ORGANIZATION OF HUMAN BODY

1.1 Cells

Cells are the

smallest independent units
of living matter and there
are trillions of them within
the body. They are too
small to be seen with the
naked eye, but when
magnified using a
microscope different types
can be distinguished by
their size, shape and the
dyes they absorb when
stained in the laboratory.
Each cell type has become
specialized, enabling it to
carry out a particular
function that contributes to
body needs. In complex
organisms such as the
human body, cells with
similar structures and
functions are found
together, forming tissues.

1.2 Tissues

Tissue consists of a
group of cells that work
together to accomplish one
or more specific functions.
In an adult human, there
are only four distinct types
Figure 1.2 Somatic cells vs. Germ cells

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of tissue.

1.3 Organs

Organs are made up of a

number of different types of tissue
and have evolved to carry out a
specific function. Figure 1.1
shows that the stomach is lined
by a layer of epithelial tissue and
that its wall contains layers of
smooth muscle tissue. Both
tissues contribute to the functions
of the stomach, but in different
ways.

1.4 Systems

Systems consist of a
number of organs and tissues that Figure 1.3 Types of Human tissues
together contribute to one or more survival needs of the body. For example, the
stomach is one of several organs of the digestive system, which has its own specific
function. The human body has several systems, which work interdependently
carrying out specific functions. All are required for health.

II – BODY CAVITIES

The body organs are contained and protected within four cavities: cranial,
thoracic, abdominal, and pelvic.

2.1 Cranial Cavity

Also known as
intracranial space, is the
space within the skull. The
space inside the skull is
formed by eight cranial
bones known as the
neurocranium. The
neurocranium is the upper
back part that forms the
protective case around the
brain. The presence of the
Figure 1.4 Bones forming the right half of the cranium and the face

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cerebrospinal fluid makes a cushion for safety of brain inside the cranial cavity.
2.2 Thoracic Cavity
Also called chest cavity, the second
largest hollow space of the body. It is enclosed
by the ribs, the vertebral column, and the
sternum, and is separated from abdominal
cavity by a muscular and membranous
partition, the diaphragm. The thoracic cavity
has compartments: the mediastinum and two
pleural cavities.

Figure 1.5 Structures forming the walls of the thoracic

cavity and associated structures

2.3 Abdominal Cavity

The abdominal
cavity is a large cavity
found in the torso
between the thoracic
cavity, and the pelvic
cavity. A protective layer
that is called the
peritoneum, which plays a
role in immunity,
supporting organs, fat
storage, lines the abdominal cavity.

2.4 Pelvic Cavity

A body cavity that is bounded by the bones of the bones of the pelvis. Its
oblique roof is the pelvic inlet (the superior opening of the pelvis). Its lower boundary
is the pelvic floor. The pelvic cavity primarily contains reproductive organs, the
urinary bladder, the pelvic colon, and the rectum.

Figure 1.7 Female reproductive organs and other structures in Figure 1.8 Male reproductive organs and other structures in the
the pelvic cavity. pelvic cavity.

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III – Body Plane

There are three body planes,

which lie at right angles to each other.
These divide the body into sections
and are used to visualize or describe
its internal arrangement from different
perspectives. The anatomical position
is used as a reference position in
descriptions using body planes.

Figure 1.9 Regions of the abdominal cavity.

Median plane. When the body is divided

Figure 1.10 Body Planes
lower parts. This may be at any level e.g. through the cranial cavity, thorax,
abdomen, a limb or an organ.
IV – DIRECTIONAL TERMS
longitudinally through the midline into right
and left halves it has been divided in the
median plane. A sagittal section is any
section made parallel to the median plane.
Coronal plane. A coronal or frontal section
divides the body longitudinally into its
anterior (front) and posterior (back) sections.
Transverse plane. A transverse or
horizontal section provides a cross section
dividing the body or body part into upper and
Anatomical position. The body is upright position with the
head facing forward, the arms at the sides with palms of the
hands facing forward with the heels of the feet together.

These paired terms are used to describe the location of body parts in relation to
others.
Directional Terms Meaning
Medial Structure is nearer to the midline. The heart is medial to the humerus
Lateral Structure is further from the midline or at the side of the body.
The humerus is lateral to the heart
Proximal Nearer to a point of attachment of a limb, or origin of a body part.
The femur is proximal to the fibula
Distal Further from a point of attachment of a limb, or origin of a body part.
The fibula is distal to the femur
Anterior/Ventral Part of the body being described is nearer the front of the body.
The sternum is anterior to the vertebrae
Posterior/Dorsal Part of the body being described is nearer the back of the body.
The vertebrae are posterior to the sternum
Superior Structure nearer the head. The skull is superior to the scapulae
Inferior Structure further from the head. The scapulae are inferior to the skull
Table 1 Common directional terms.

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V – REVIEW OF SURFACE ANATOMY

Significance to radiography
Surface anatomy is a descriptive science dealing with anatomical features
that can be studied by sight and palpating the human body without dissecting. This
knowledge is important for radiologic technologist to know as many surface
landmarks are used for positioning. Also a good understanding of surface anatomy
enables the radiologic technologist to perform the most beneficial views for the
patient.

Body Surface Landmarks

Figure 1.11 Body landmarks

Head
Surface
Landmarks

Figure 1.12 Anatomical landmarks of head and face. Figure 1.13 Anatomical landmarks of head and face.

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Lesson Introduction to Pathology

2

Now that you have reviewed your knowledge

about human body, you can now start to study about
pathology. Knowledge and understanding of pathology
is essential for all general medical practitioners and
specialists since unless they know the causes,
mechanisms, nature and type of disease, and
understand the language spoken by the pathologist in
the form of laboratory reports, they would not be able to
institute appropriate treatment or suggest preventive
measures to the patient.

Learning objectives
On completion of this lesson, you should be able to:
 Define pathology
 List pathological terminologies
 Know and differentiate some subdivisions of pathology
 Understand and explain the classification of diseases

Abstraction

DEFINITION OF PATHOLOGY

The word ‘Pathology’ is derived from two Greek words—pathos meaning

suffering, and logos meaning study. Pathology is, thus, scientific study of structure
and function of the body in disease; or in other words, pathology consists of the
abnormalities that occur in normal
DISEASE
anatomy (including histology) and - It is any abnormal change in the function
physiology owing to disease. Pathologists or structure within the body
- It is a morbid process
are the diagnosticians of disease. - It can affect one or more organs

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SUBDIVISIONS OF PATHOLOGY

Depending upon the species studied, there are various disciplines of

pathology such as human pathology, animal pathology, plant pathology, veterinary
pathology, poultry pathology etc. Comparative pathology deals with the study of
diseases in animals in comparison with those found in man.
Human pathology is the largest branch of pathology. It is conventionally
divided into General Pathology dealing with general principles of disease, and
Systemic Pathology that includes study of diseases pertaining to the specific organs
and body systems. Pathology has come to include the following subspecialities:

A. HISTOPATHOLOGY. Histopathology, C. CHEMICAL PATHOLOGY. Analysis of

used synonymously with anatomic biochemical
pathology, pathologic anatomy, or morbid constituents of blood, urine, semen, CSF
anatomy, is the classic method of study and and other body
still the most useful one which has stood the fluids are included in this branch of
test of time. The study includes structural pathology.
changes observed by naked eye
examination referred to as gross or D. IMMUNOLOGY. Detection of
macroscopic changes, and the changes abnormalities in the
detected by light and electron microscopy immune system of the body comprises
supported by numerous special staining immunology and
methods including histochemical and immunopathology.
immunological techniques to arrive at the
most accurate diagnosis. Anatomic E. EXPERIMENTAL PATHOLOGY. This is
pathology includes the following 3 main defined as production of disease in the
subdivisions: experimental animal and its study. However,
all the findings of experimental work in
1. Surgical pathology. It deals with the study animals may not be applicable to human
of tissues removed from the living body. beings due to species differences.

2. Forensic pathology and autopsy work. F. GEOGRAPHIC PATHOLOGY. The study

This includes the study of organs and
tissues removed at postmortem for
medicolegal work and for determining the
underlying sequence and cause of death.
Postmortem anatomical diagnosis is helpful
to the clinician to enhance his knowledge
about the disease and his judgement while
forensic autopsy is helpful for medicolegal
purposes.
3. Cytopathology. Though a branch of
anatomic pathology, cytopathology (studies
and diagnoses disease on the cellular level)
has developed as a distinct subspeciality in
recent times. It includes study of cells shed
off from the lesions (exfoliative cytology) and
fine-needle aspiration cytology (FNAC) of
superficial and deep-seated lesions for
diagnosis).
of differences in distribution of frequency and
type of diseases in
populations in different parts of the world
forms geographic pathology.
G. MEDICAL GENETICS. This is the branch
of human genetics that deals with the
relationship between heredity and disease.
There have been important developments in
the field of medical genetics e.g. in blood
groups, inborn errors of metabolism,
chromosomal aberrations in congenital
malformations and neoplasms etc.
H. MOLECULAR PATHOLOGY. The
detection and diagnosis of abnormalities at
the level of DNA of the cell is included in
molecular pathology.

B. HAEMATOLOGY. Haematology deals

with the diseases of blood. It includes
laboratory haematology and clinical

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DISEASE AND ILLNESS

A term commonly confused with disease is

illness. While disease suggests an entity with a
cause, illness is the reaction of the individual to
disease in the form of symptoms (complaints of the
patient) and physical signs (elicited by the clinician).
Though disease and illness are not separable, the
study of diseases is done in pathology while the
learning and management of illnesses is done in wards and clinics.
In addition to disease and illness, there are syndromes (meaning running together)
characterized by combination of symptoms caused by altered physiologic processes.

Illness – first person perspective

Disease – professional perspective
Sickness – societal perspective

TERMINOLOGY IN PATHOLOGY

It is important for a beginner in

pathology to be familiar with the
language used in pathology:

 Patient is the person affected by disease.

 Lesions are the characteristic changes in tissues and cells produced by disease
in an individual or experimental animal.
 Etiology is the study of the cause of disease.
 Idiopathic the cause of disease is unknown.
 Iatrogenic cause is the result of the treatment given to the patient.
 Pathologic changes or morphology consist of examination of diseased tissues.
 Pathologic changes can be recognized with the naked eye (gross or macroscopic
changes) or studied by microscopic examination of tissues.
 Causal factors responsible for the lesions are included in etiology of disease (i.e.
‘why’ of disease).
 Mechanism by which the lesions are produced is termed pathogenesis of disease
(i.e. ‘how’ of disease).
 Functional implications of the lesion felt by the patient are symptoms and those
discovered by the clinician are the physical signs.
 Clinical significance of the morphologic and functional changes together with
results of other investigations help to arrive at an answer to what is wrong
(diagnosis), what is going to happen (prognosis), what can be done about it
(treatment), and finally what should be done to avoid complications and spread
(prevention) (i.e. ‘what’ of disease).

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 Syndrome – a group of signs and synptoms that occur together and characterize
a particular abnormality or condition.
 Ischemia refers to the interference with the blood supply to an organ or part that
deprives its cells and tissues of oxygen and nutrients.
 Infarct is localized area of schemic necrosis within a tissue or organ.
 Hemorrhage implies rupture of a blood vessel.
o External
Arterial – the blood is typically bright red to yellowish in color, due
to highg degree of oxygenation. A wound to a major artery could result in
blood ‘spurting’ in time with the heartbeat, several metes and the blood
volume will rapidly reduce.
Venous – blackish in color due to the lack of oxygen it transports
and flows in steady state.
Capillaries – occurs in all wounds. Blood loss is usually controlled
and bleeding could be described as ‘trickle’ of blood.
o Internal
A loss of blood from a blood vessel that collects inside the body. Usually
not visible from the outside.
o Others
Hematoma – result of a break in a blood vessel causes a pooling of
blood below the surface of the skin, organ, or structure.
Ecchymosis – type of hematoma commonly called bruise or
contusion. Capillaries below the skin are damaged
Purpura – Red or purple spots on the body caused by a
hemorrage. (4 to 10 mm in diameter)
Petechia – Type of purpura consist of very small red or purple
spots on the body. (less than mm in diameter)
 Edema abnormal accumulation of fluid in the body cavities or intercellular space.
(Swelling due to fluid built up)
o Abnormal fluid
Transudates – Extracellular fluids consist of water usually clear
contains low cell count.
Exudates – Fluid filters from circulatory system into lesions
contains water, pus, sometimes blood

ALTERATION OF CELL GROWTH

Atrophy refers to a reduction in the size or the number of cells in an organ or tissue with
a corresponding decrease in function.
Hypoplasia – under develop or incomplete development.
Aplasia – Failure to develop or absent development.
Hypertrophy refers to an increase in the size of cells of a tissue or organ in response to
a demand for increased function.
Hyperplasia - an enlargement of an organ or tissue caused by an increase in the
amount of organic tissue that results from cell proliferation.
Dysplasia - abnormal development of cells within tissues or organs.

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CLASSIFICATION OF DISEASES
CLASSIFICATION OF DISEASES
STRUCTURAL DISEASES
Genetic and Developmental
Diseases
Acquired Injuries/Traumatic
Inflammatory
Degenerative
Neoplastic
Metabolic
A. Genetic and developmental
diseases
•Congenital – birth defect, is a
condition present at birth regardless of
its cause.
•Hereditary – inherited disease or
disorder. Are passed on from one
generation to another through defective
genes.
B. Inflammatory diseases
•Infective – invasion of
microorganisms such as virus, bacteria,
or fungi
•Allergic – over reaction of body’s
own defenses
•Toxic – having chemical nature
that is harmful to health or lethal if
consumed or otherwise entering into the
body in sufficient quantities.
C. Degenerative disease
– result of continuous process
based on degenerative cell changes,
affecting tissue or organs, which will
increasingly deteriorate over time.
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FUNCTIONAL DISEASES
Impairs normal functioning of bodily
processes that remains largely
undetected under examination,
dissection, or even under
microscope.
D. Metabolic disease
– occurs when abnormal
chemical reactions in your body disrupt
this process. You can develop
metabolic disease or disorder when
some organs, such as your liver
become diseased or do not function
normally.
E. Traumatic injury
– refers to physical injuries of
sudden onset and severity which
require immediate medical attention. It
caused by a variety of external forces
which affect the body.
F. Neoplastic disease
– a condition that cause tumor
growth – both benign and malignant.
TREATMENT AND CURE
A treatment improves a condition and improves
the patient’s quality of life, while a cure would completely
remove the disease from the patient. The term cure
means that, after medical treatment, the patient no
longer has the particular condition anymore.
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Lesson General Basis of

3
Pathologic Condition

Now that pathology has been introduced to you,

you will get to know the general basis of pathologic
condition. A pathological condition is the one caused by
disease rather than occurring physiologically. One of
those is inflammation, which we will discuss in this
lesson.

Learning objectives
On completion of this lesson, you should be able to:
 Define inflammation and know its causes
 Differentiate the two types of inflammation
 Know its outcomes and effects
 List some examples of diseases

Abstraction

INFLAMMATION

DEFINITION AND CAUSES. Inflammation is defined as the local response of living

mammalian tissues to injury due to any agent. It is a body defense reaction in order
to eliminate or limit the spread of injurious agent, followed by removal of the
necrosed cells and tissues.

The agents causing inflammation may be as under:

1. Infective agents like bacteria, viruses and their toxins, fungi, parasites.
2. Immunological agents like cell-mediated and antigen-antibody reactions.

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3. Physical agents like heat, cold, SIGNS OF INFLAMMATION

radiation, mechanical trauma. The Roman writer Celsus in 1st century A.D. named the
famous 4 cardinal signs of inflammation as:
4. Chemical agents like organic and
 rubor (redness);
inorganic poisons.  tumor (swelling);
5. Inert materials such as foreign bodies.  calor (heat); and
 dolor (pain).
To these, fifth sign functio laesa (loss of function) was
Thus, inflammation is distinct from later added by Virchow.
infection—while inflammation is a
protective response by the body to variety of etiologic agents (infectious or non-
infectious), while infection is invasion into the body by harmful microbes and their
resultant ill-effects by toxins.

TYPES OF INFLAMMATION

Depending upon the defense capacity of

the host and duration of response,
inflammation can be classified as acute and
chronic.

A. Acute inflammation is of short duration

(lasting less than 2 weeks) and represents
the early body reaction, resolves quickly
and is usually followed by healing.

The main features of acute inflammation

are:
1. accumulation of fluid and plasma at the Figure 1.3 Redness (rubor) and swelling (tumour), both
characteristic features of acute inflammation
affected site;
2. intravascular activation of platelets; and
3. polymorphonuclear neutrophils as
inflammatory cells.
ACUTE INFLAMMATION
Sometimes, the acute inflammatory
response may be quite severe and is
termed as fulminant acute inflammation. Acute inflammation begins within seconds
to minutes following injury to tissues.
B. Chronic inflammation is of longer
duration and occurs either after the
causative agent of acute inflammation FATE OF ACUTE INFLAMMATION
persists for a long time, or the stimulus is
such that it induces chronic inflammation
from the beginning. A variant, chronic The acute inflammatory process can
active inflammation, is the type of chronic culminate in one of the following
inflammation in which during the course of outcomes:
disease there are acute exacerbations of
activity.
1. Resolution. It means complete return
The characteristic feature of chronic to normal tissue following acute
inflammation is presence of chronic
inflammatory cells such as lymphocytes,
inflammation. This occurs when tissue
plasma cells and macrophages, granulation changes are slight and the cellular
tissue formation, and in specific situations changes are reversible e.g. resolution in
as granulomatous inflammation.
lobar pneumonia.
In some instances, the term subacute
inflammation is used for the state of
inflammation between acute and chronic.
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2. Healing. Healing by fibrosis takes place when the tissue destruction in acute
inflammation is extensive so that there is no tissue regeneration. But when tissue
loss is superficial, it is restored by regeneration.

3. Suppuration. When the pyogenic bacteria causing acute inflammation result in

severe tissue necrosis, the process progresses to suppuration. Initially, there is
intense neutrophilic infiltration. Subsequently, mixture of neutrophils, bacteria,
fragments of necrotic tissue, cell debris and fibrin comprise pus which is contained in
a cavity to form an abscess. The abscess, if not drained, may get organised by
dense fibrous tissue, and in time, get calcified.

4. Chronic inflammation. Persisting or recurrent acute inflammation may progress

to chronic inflammation in which the processes of inflammation and healing proceed
side by side.

Figure 3.1 Fate of acute inflammation.

MORPHOLOGY OF ACUTE INFLAMMATION

Inflammation of an organ is usually named by adding the suffix-itis to its Latin name
e.g. appendicitis, hepatitis, cholecystitis, meningitis etc. A few morphologic varieties
of acute inflammation are described below:

1. PSEUDOMEMBRANOUS INFLAMMATION. It is
inflammatory response of mucous surface (oral,
respiratory, bowel) to toxins of diphtheria or irritant
gases. As a result of
denudation of epithelium, plasma exudes on the
surface where it coagulates, and together with
necrosed epithelium, forms false membrane that
gives this type of inflammation its name.

Figure 3.2 Person who has Pseudomembranous

Diphtheria

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2. ULCER. Ulcers are local defects on the

surface of an organ produced by
inflammation. Common sites for
ulcerations are the stomach, duodenum,
intestinal ulcers in typhoid fever, intestinal
tuberculosis, bacillary and amoebic
dysentery,
ulcers of legs due to varicose veins etc.

Figure 3.3 Symptoms of stomach ulcer

3. SUPPURATION (ABSCESS
FORMATION). When acute bacterial
infection is accompanied by intense
neutrophilic infiltrate in the inflamed tissue,
it results in tissue necrosis. A cavity is
formed which is called an abscess and
contains purulent exudate or pus and the
process of abscess formation is known as
suppuration. The bacteria which cause
suppuration are called pyogenic. Figure 3.4 Remnant of a drained pulmonary abscess at post-mortem
Microscopically, pus is creamy or opaque in appearance and is composed of
numerous dead as well as living neutrophils, some red cells, fragments of tissue
debris and fibrin. In old pus, macrophages
and cholesterol crystals
are also present.

4. CELLULITIS. It is a diffuse inflammation

of soft tissues resulting from spreading
effects of substances like hyaluronidase
released by some bacteria.

5. BACTERIAL INFECTION OF THE

BLOOD. This includes the following 3
conditions:
i) Bacteraemia is defined as presence of
small number of bacteria in the blood
which do not multiply significantly.
ii) Septicaemia means presence of rapidly
multiplying, highly pathogenic bacteria in
the blood e.g. pyogenic cocci, bacilli of
plague etc. (Blood poisoning)
Figure 3.5 Cellulitis

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iii) Pyaemia is the dissemination of

small septic thrombi in the blood
which cause their effects at the site
where they are lodged. This can
result in pyaemic abscesses or
septic infarcts.

CHRONIC INFLAMMATION Complications

Although chronic inflammation progresses

DEFINITION AND CAUSES.
Chronic inflammation is defined as
prolonged process in which tissue
destruction and inflammation occur at the
same time.
Chronic inflammation can be caused by
one of the following 3 ways:
silently, it is the cause of most chronic diseases and
presents a major threat to the health and longevity of
individuals. Inflammation is considered a major
contributor to several diseases.
• Cardiovascular diseases
• Cancer
• Diabetes
• Rheumatoid arthritis
• Allergic asthma
• Chronic obstructive pulmonary disease (COPD):
• Alzheimer's disease

1. Chronic inflammation following acute inflammation.

When the tissue destruction is extensive, or the bacteria survive and persist in small
numbers at the site of acute inflammation e.g. in osteomyelitis, pneumonia
terminating
in lung abscess.
2. Recurrent attacks of acute Risk Factors Associated with Chronic Inflammation
inflammation. Several risk factors promote a low-level inflammatory
response. These include:
When repeated bouts of acute
inflammation culminate in chronicity of the • Age
• Obesity
process e.g. in recurrent urinary tract • Diet
infection leading to chronic pyelonephritis, • Smoking
repeated acute infection of gallbladder • Low Sex Hormones
• Stress and Sleep Disorders
leading to chronic cholecystitis.

3. Chronic inflammation starting de novo.

When the infection with organisms of low pathogenicity is chronic from the beginning
e.g. infection with Mycobacterium tuberculosis.

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