TYPHOID FEVER cause by: salmonella thyposa - enterobacteriaceae - gram negative - 2-3 um x 0.

6 - rod shape, short plump - biochemical activity: non- lactose or sucrose fermenter - produces gas from glucose and mannose salmonella produce less hydrogen sulfide in KIA(kleigers iron agar) - in TSI it resembles mustache, no gas, alkaline slant, agglutinates in Vi serotyping STRUCTURAL ANTIGEN: 1. H - flagella, protein struc 2. O - somatic cell (heat stable outer membrane) - involved in production of fever 3. Vi - outer shell envelope (made up of carbohydrate) - inhibits phagocytosis by interfering with the action of the complement sys flies: good carrier of typhoid infective dose: 10^5 localize area: ileum of the small intestines cecum lymphoid follicles * the bacilli is cytophilic - attaches itself to the intestinal cell effect on pregnant woman: fetal typhoid Widals test: detects O and H antigen also known as agglutination test what mus be needed: patient serum Payers patch: lungga ng mga salmonella gestational: the baby's weight and size is not normal mortality: 2% if prompt treatment 80% if w/o major complication: - fall in tem - rise in pusle - leucocytosis - promounced abdominal pain in RLQ - muscle spasm free air: seen in upright bdominal x-ray treatment: aminoglycoside (3-5mg/KBW) major complication: intestinal hemmorage: - pallor and sweating - hypotension - rare abdominal pain - sudden fall of temp prevention: blood transfusion Diet: high caloric food

5 cardinal signs of thyphoid fever: - high fever - splenomegaly - char. toxemia - rose spots (blanch on pressure; 2-4 mm erythematous vacoule) - stay only about 2 to 3 days - stay only on chest and abdominal region - slow pulse disproportionate to the amount of fever third week of infection: dicrotic pulse, luecopenia (low WBC): 3000-4000 - normal count: males"5000-10000 : females "5000-9500 cells/cumm to fulfill the criteria of fever of unknown origin: - patient must have an illness of at least 3 weeks duration - fever over 38.3 degrees - must remain undiagnosed after one week of study in the hospital salmonella: h2s production, non lactose HEA- blue-green with black center SS- colorless with black center macconkey: yellow to colorless EMB: colorless * if the bacteria is in the gall bladder, it is a carrier cholecystectomy: removal of gall bladder best specimen: bone marrow specimen convalescent carrier- passes the bacilli in the excreta for up to 6 months after the attack chronic carrier: thyphoid marry persistent: culture for one year treatment: fluoroquinones or ampicillin or trimethoprim with sulfamethoxazole: drug of choice if resistant in chloramphenicol non-specific treatment: paracetamol and hydrotherapeutiv measures for febrile patients steroid: for severe cases salicylates: not recommended because of possible hemmorage * the vaccine does not provide absolute immunity vaccine available: monovalent acetone typhoid vaccine: thypim Vi typhoid vaccine live oral Ty21a- vivotif berna, zerotyph thyphoid vaccine contains salmonella typhosa immunization is indicated in: - foreign travel where typhoid fever is endemic - in epidemic - intimate exposure to a known typhoid fever salmonella paratyphosa: milder, shorter incubation period - classified as: A (longer duration) and B fecal characteristic: greenish pea soup diarrhea

BACILLARY DYSENTERY - gram negative - non-sporeforming rods - non motile - no flagellar antigens - optimum temp: 37 - no growth at 45 degrees - do not produce gas from glucose - form acid with lactic acid together with formic and acetic and ethyl alcohol - no hydrolyze urea - no H2S in triple iron sugar - they do not decarboxylate lysine - shigella do not utilize acetate or mucate as a source of carbon - infective dose: 200 - infective symptoms: high fever, chills, abdominal cramps and pain accompanied by tenesmus, appear approx 24-28 hrs after ingestion - 4 serotypes of shigella: basis of somatic o antigen and carbohydrate fermentation patterns 1. shigella dysenteriae - shigas bacillus (most virulent)(non mannitol)(+ in tartrate)(variable in ONPG) 2. shigella flexneri - strong bacillus (negative in ONPG) 3. shigella boydii- neucastle manchester (variable in ONPG) 4. shigella sonnei- duvals bacillus (least virulent)(late lactose fermenter; 4-7 days) contains beta galactosidase (+ in ONPG and tartrate utilization) - all of these can ferment glucose ONPG- orthonitrophenyl beta galactosidase test cultural characteristics: Macconkey: colorless EMB: colorles Deoxycholate citrate agar: colorless Salmonella-shigella agar: colorless without black center Hektoen enteric agar: blue-green without black center Xylosine lysine deoxycholate: red Shigella virulence: dependent on the presence of a 220Kda plasmid associated with invasiveness test of invasiveness: iinoculating the rabbit or guinea pig conjunctiva with the suspension of the organism and obserbing for purulent sicharge and opacification(mamuta) Sereny test or kerato-conjunctive test: test for invasiveness soreeyes; redness. Mucopurulent discharge and opacification shiga toxin: produced by S. dysenteriae possess cytotoxin, neurotoxin and enterotoxin activity and consist of 2 chains: a. single A subunit is responsible for biological activity b. 5B subunits are responsible for binding the toxin to suceptible cells Treatment: Fluid replacement theraphy Specific treatment: ampicillin - the role is variable and depend upon the organism and severity of the disease contraindicated treatment for shigellosis: amoxicillin (because it is only a hydroxy derivative of ampicillin) anti motility drugs because it will decrease the peristalsis tetracycline for children 10 yrs old because of calcium deposition on teeth and bones the enterotoxin in shigella bacillus can cause paralysis of the animals rabbit illeal loop test- to show that there is paralysis. (+) accumulation of fluid, inflammation Drugs for resistant strains: nalidixic acid; 4-fluoroquinolones Gay bowel syndrome: another name for shigellosis for those who are homosexual exotoxin: when toxins are excreted from the bacterial cells producing them are dissolved in the sorrounding culture medium endotoxin: when toxins are retrained within the bacterial body

AMOEBIC DYSENTERY - common name: amoebiasis, walking dysentery, protozoal dysentery, entamoebiasis DIFFERENCES OF DIARRHEA WITH DYSENTERY: diarrhea: induces secretion of fluid in the small intestines stool passage is 5-10 stool dysentery: -

more of the large intestines/ colon composition: blood, mucus, pus 10-30 stool passage per day (average: 20)

differentiation shigella and amoebiasis iodine rx: motility test: blood in stool + red currant stool jelly + black tarrid

* shigella flattens microvilli which causes the malabsorption of starch and be released in the feces instantly Three stages of amoeba: 1. tropozoite 2. precyst 3. cyst cyst: infective stage has chitin which makes it resistant to environmental factors

tropozoites - contains RBC in inclusion- feeding stage- invasive stage - irregular finger like shape PVA( polyvinyl alcohol) - fixative for trophozoite - for fresh specimen formalin- for preserving cysts precyst: 1 nuclei immature cyst: 2 nuclei mature cyst: 4 nuclei synoidoscopy- look for ulceration in the colon - look for tropozoite Amoeboma- inserts itself between tissues resulting to inflammation How to destroy cyst: boiling water, dessication, direct sunlight, heat or by adding 200ppm of iodine Lab findings: eosinophilia Charcot-leyden crystals: presence of eosinophilia in the stools is and indication eosinophil disintegration conclusion: parasitism, astma, allergy staining of the amoeba: iron hematoxylin wheatley trichrome stain

Treatment: classification of drugs a. intestinal b. direct-tissue c. invasive-tropho d. extraintestinal e. indirect luminal f. non-invasive cyst luminal: iodoquinol, diloxanide furoate, paramomycin - act on organisms in the bowel lumen but are ineffective against in the bowel wall of other tissues Tissue: emetine, dihydroemetine - act on the organisms in the bowel wall and in other tissues but not on amoebas in the bowel lumen A. asymptomatic intestinal infection diloxanide furoate or iodoquinol are 80-85% B. mild to moderate intestinal infection iodoquinol and tetracycline C. severe intestinal infection fluid electrolyte therapy and opiates- used cautiously because of potential risk of toxic mycolon D. hepatic abscess hospitalization and bed rest necessary *metronidazole (flagyl)- drug of choice for all Sigmoidoscopy - is of value in the symptomatic cases. The mucosal lesions should be aspirated and the material examined for trophozoite - biopsy material obtained from such lesions are stained with PAS (periodic acid shciff) seen to reveal trophozoites extra intestinal amoebiasis may be proven using several serological testL 1. indirect hemagglutination 2. direct immunofluorescence 3. counter-current immunoelectrophoresis 4. complement fixation 5. agar gel diffusion

cholera el tor epidemic and asiatic cholera 2 biotypes of v. cholerae: classic el tor biotype facultative anaerobes optimum growth: 37 degrees arrested at: 14-42 grow fast at ph: 6-9 Test to differentiate the two bitypes 1. direct hemagglutination test (+) eltor agglutinates sheeps RBC and chicken red cell

2. sensitivity to polymyxin (+) classic (-) el tor is resistant 3. sensitive to cholera phage IV (murkerjee) (+) classic is sensitive (-) el tor is resistant 4. hemolysis test (+) el tor 5. Voges Proskauer (-) classic (+) el tor: purple and pink in color Serotypes: A,C: Inaba or original type AB: ogawa or variant ABC: hikojima or middle choleragen (enterotoxin): activates intracellular adenylate cyclase that converts ATP to cyclic adenosime monophosphate - no sodium passes the cell - losing bicarbonates will cause acidosis - potassium will cause cramps at toes and fingers - when the cell looses water, it will get its water supply in the blood causing dehydration - causes odorless sweet fishy odor or diarrhea rice watery diarrhea - heat labile enterotoxin - causes hypersecretion of the isotonic electrolyte solution by an intact small bowel mucosa resulting from loss of electrolytes infective dose: 100-1000 sympotms: - washer womans hands cause by dehydration cholera cot: measures urine and feces output monitoring the dehydration (signs): - pulse rate - urine output - skin turgor cholera red test (nitroso indole reaction): - in peptone medium with tryptophan if there is vibrio tryptophanase is present that will release the indole group and also reduces NO3, - H2SO4 upon addition causes red color due to nitrosoindole oxidase test: dark purple color (+) w/n 10 secs mucoid test/string test: use MEA (meat extract agar) suspend at 18 to 24, gelatin agar, taurocholate tellurite gelatin agar or kleigars iron agar + 0.5% aq. soln. of sodium desoxycholate (+) result is turbidity loss and becomes mucoid (malagkit)

cause of death: - hypovolemic shock (diarrhea) - metabolic acidosis - renal failure clinical symptoms in cholera: - aphonia: voices is high pitched and inaudible - sunken eyes, wrinkled skin - muscle cramps - metabolic acidosis starts from: diarrhea - rice watery stool rich in water, bicarbonate and glucose treatment for dehydration: Oral rehydration salt rice watery tools contains 10^9 vibbrio per mL signs of severe dehydration: - in infants, choler causes sunken fontanel - sunken eyeballs - loss of turgor or elasticity of skin - cold clammy sweat - decrease blood pressure - scaphoid abdomen uremia: accumulation of waste products like urea in the blood due to tubular necrosis oliguria: abnormal decrease in secretion of urine anuria: no secretion of urine Dark field microscopy on a wet mount of a fresh stool: schoals of fish discerened with inaba and ogawa specific antigen best selective media: TCBS which grows as a typical opaque yellow colonies if a delay in sample processing is expected: Carey-Blair transport medium or alkaline-peptone-water-enrichment medium should be inoculated as well stool smears that are stained by fuchsin solution appear as: shoals of fish over hydration: observation of neck veins ausculation of lungs ideal bed for patients with cholera el tor: cholera cot adequacy of hydration is confirmed by frequent clinical evaluation: - pulse rate and strength - skin turgor - urine output cholera vaccine: a sterile suspension of killed vobrio of the inaba and ogawa strains in nss ot suitable diluent. - it contains about 8 billion of cholera per mL killed and preserved by the addition of 0.5 % phenol remarks of immunity: immunity lasts for 6 months or less. protection depends largely on booster doses acceptable composition: glucose- 20g/L sodium chloride- 4g/L NaHCO3- 4g/L KCl- 1g/L

Eschericha Coli (colon bacillus) Predominant facultative specie in the large bowel - in humans the bowel is usually colonized within 40 hours of birth. that is why E. Coli is considered to be a part of human normal intestinal flora - absence: index of suitability of water - appendages: 1. flagella- motility 2. pili/fimbrae- used to adhere epithelial lining 3. sex F pilus- for genetic exchange from a donor to a recipient E. coli family: enterobactericiae *the flagella are arranged in bundles DOH test for water: 1. presumptive test: durhams fermentation tube- uses liquid differential media a. Brilliant green bile lactose broth- eliminates gram negative - allows the growth of the coliform group of bacteria like E.coli, enterobacter - (+) production of gas; formation of bubbles 2. confirmatory test- makes use of a solid differential media a. EMb- (+) red black colonies with a green metallic lustre (in reflected light) 3. completed test: makes use of lactose broth and gram staining method IMVIC TEST- DIFFERENTIATES E. COLI WITH OTHER ENTEROBACTER GROUP 1. indole test- tryptone broth rich in tryptophan - the bacteria converts it "W" to pyruvic acid, ammonia, and indole. On addition of kovacs reagent (p-dimethyl amino benzaldehyde) - a red ring if E. coli - brown color for enterobacter 2. methylred: determination of PH of a dextrose broth culture after 2 to 4 days of incubation; indicator is added (+) red color due to accumulated acidity (-) yellow color for enterobacter 3. Voges Proscauer: qualitative test for the presence of acetyl methyl carbinol or acetoin - after 2-4 days growth in glucose peptone water medium, 5mL of 10% KOH is added - carbinol is a synonym of methanol - on standing the presence of alkali, AMC is oxidized to diacetyl which reacts with the const. of peptone to give pink/red for 20-30 mins (+) entero pink/red (-) E.coli yellow - ragents: Barritts A (alpha napthol) and B barritts (KOH) - these reagent are added in which AMC is present 4. citrate utilization test - simmons citrate agar is inoculated and incubated for 24-28 hrs. - contains ammonium phosphate as a source of nitrogen and citrate as carbon - if test org. can utilize citrate, alkaline conditions will be created and medium willl turn (+) for enterobacter. from the orgiginal green to a deep prussian blue. (-) for e.coli MAC E.coli: flat red pinnk colonies sorrounded by a red zone of precipitated bile salts salmonella and S. dysenteriae: colorles EMB E.coli: red-black colonies that has a definite metallic green sheen salmonella andS. dysenteriae: colorless HEA (Hektoen enteric agar) E.coli yellow orange/carrot like color S. dysenteriae: ble green without black center salmonella with black center

XLD (xylose lysine deoxycholate) e.coli: yellow salmonella and S. dysenteriae: red SS agar e.coli: pink(very rare since e.coli will not favor this medium) S. dysenteriae: colorless without black center salmonella: with black center Deoxycholate citrate agar e.coli: deep red pink salmonella and S. dysenteriae: colorless TYPES OF E.COLI A. enterotoxigenic e.coli: turisha, travellers diarrhea, montezumas revenge, new delhi belly - entero toxin producing e.coli - produces rice watery diarrhea - produces two types of toxin: a. LT type: heat labile toxin - a protein with a MW of 73,000 daltons destroyed by heating at 65 degrees for 30 mins stimulates the activity of a membrane bound adenylate cyclase (CAMP) - cAMP- prevents sodium inside the cell - test for this type of toxin: 1. rabbit ligated ileal loop test (+) accumulation of fluid 2. Y1 mouse adrenal cell/chinese hamster ovary (+) morphological change a. ST tpe: heat stable toxin - a protein with a MW of 1500-2000 daltons - not destroyed by heating at 100 for 30 mins - stimulates guanylate cyclase - CGMP- removes sodium inside the cell causing dehydration - test for this type of toxin: 1. suckling mouse (infant mouse test) - ST toxin injected in the stomach. after 4 hrs, the mice are killed and the intestines examined for dilation with fluid - the intestine are also called removed and the ratio of gut weight to remaining body weight is used as an objective to measure fluid accumulation (+) intestinal dilation in suckling mouse after injection of culture filtrates into the stomach accumulation of fluid and weight increases - the pathogenicity of ETEC lies not only in the enterotoxin but also in colonization factor antigen (CFA) which is present only in ETEC -CFA gives adherence property - Coli surface antigen (CSs) facilitates adherence of e. coli strains to intestinal epithelium B. Enteroinvasive E. coli:O124 - because f its invasiveness to the intestines, there is bloody diarrhea - possess a virulence plasmid (140mDa) similar to shigella - invades, penetrate, and multiply within the epithelial cells - test for invasiveness: sereny test or guinea eye pig kerato-conjunctivitis test (+) prulent discharge and opacification - similar both biochemically and serologically to shigella

C. Enteropathogenic E.Coli: 055: H7 (EPEC) - also called as infantile diarrhea - affect only patients less that 3 years old - colonizes in the epithelial lining because of enteropathogenic E.coli adherence factor (EAF) plasmid - the adherence has been shown to be mediated by plasmids and to be associated with virulence - tests fpr this organism: specimen: using hep-2-cells or HelA cells (+) EPEC forms microcolonies adhering to hep-2-cells - stool: slimy, pasty - diarrhea: without blood but with mucus - symptoms: vomitting, low grade fever, malaise - EPEC adhere to the intestinal epithelium to form colonies on the enterocyte plasma membrane D. Enteroadherent E.coli/Enteroaggregate E.coli - adheres to small intestines mucosa - causes diarrhea for 14 days (persistent non bloody) - virulence mechanism: attachment and effacement - EAST plasmid: a distinctive heat labile plasmed-encoded toxin - tests for EAEC: hep-2-cells and Hela cells - (+) brick like parrern because of its aggregative property E. Enterohemorrhagic E.coli - E coli serotype 0157:H7 - also called as hamburger's disease - cause of sporadic hemmorhagic colitis (HC) when improperly cooked meat has served as the mahor vehicle of transmission (uncooked hamburger) - illness is characterized by: - acute onset of cramps - absent or low grade fever - watery diarrhea that may rapidly progeress to bloody diarrhea - produces "verocytotoxin" - responsible for edema - diffuse bleeding in the colon - hemolytic uremic syndrome (HUS) - hemolytic uremuic syndrome - sudden rapid destruction of RBC causes acute renal failure due partly to obstruction of small arteries in the kidneys. the hemolysis also causes a reduction in the no. of platelets which can lea to severe hemorrhage. - may occur as a result of septicemia - increases creatinine, anemia bleeding, renal failure - verotoxin - shigella like toxin - responsible for hemorrhage - shows RBC fragmentation - active attached to new cells - African green monkey kidney cells - cytophatic effects on vero cells - thrombotic thrombocytopenic purpura - an reduction in the no. of platelets in the bloood - this results in: - bleeding into the skin (purpura) - spontaneous bruising - prolonged bleeding after injury - thrombocytopenia - may result from renal failure of platelet production or excessive destruction of platelets - test for EHEC a. using Sorbitol macconkey agar - E.coli 0157:H7 strain has the ability to ferment sorbitol at 24 hours b. latex agglutination test