PBL 2 GBMS 3

PPT BY: Ibrahim Mukassabi

 OBJECTIVES
Pathology
1. Define edema with related terms.
2. Outline types of edema with examples
3. Discuss the pathogenesis of edema.
4. Outline causes of edema with examples.
Physiology
5. Outline the function of levels of CNS.
Microbiology
6. Classify medical important gram-negative bacteria
7. Outline general properties, clinical features,
pathogenicity and lab diagnosis of Neisseria
Pharmacology
8. Discuss the adverse effects of adrenaline/
epinephrine and the receptors.
Pathology
1.Define edema with related terms.

Definition
Edema is defined as abnormal and excessive accumulation of fluid in the
interstitial tissue spaces and serous cavities
The accumulation of fluid in tissues (edema) or body cavities (effusions)

Related terms
Effusions in the pleural cavity (hydrothorax)
Effusions in the pericardial cavity (hydropericardium)
Effusions in the peritoneal cavity (ascites)
1.Outline types of edema with example.
Types
(1) Localized or generalized.
Localised: When limited to an organ or limb e.g. inflammatory edema allergic edema
lymphatic edema and cerebral edema.
Generalised (anasarca): When it is systemic in distribution, particularly noticeable in
the subcutaneous tissues e.g. renal edema cardiac edema nutritional edema

(Generalized edema) (Localized edema)

1.Outline types of edema with example.

(2) Depending upon fluid composition, edema fluid may be:

• Transudate :
• Exudate:
1.Outline types of edema with example.

(3) Pitting edema and non-pitting edema:

Momentary pressure of finger produces a depression known as pitting edema
1.Outline types of edema with example.
Example:
Cerebral edema
Renal edema
• Cerebral edema or swelling of the brain is the most life-
• Generalised edema occurs in certain
threatening example of edema
diseases of renal
Pulmonary edema
origin
• Acute pulmonary edema is the most important form of
• Grossly, the affected organ is enlarged
local
and heavy with
edema as it causes serious functional impairment
tense capsule
• The fluid accumulation is not only in the tissue space but
Cardiac edema
also in the pulmonary alveoli.
• Generalised edema develops in right-
Nutritional edema
sided and
• Edema due to nutritional deficiency of proteins, vitamins
congestive cardiac failure
and chronic alcoholism occurs on legs but sometimes may
Hepatic edema
be more generalised.
• Slows regular blood flow to the liver.
1.Discuss the pathogenesis of edema.

1. Decreased Plasma Oncotic Pressure:

• Low protein levels (hypoproteinaemia) weaken the force pulling fluid into blood
vessels.
• Fluid leaks out, causing swelling, especially in areas like the abdomen and
ankles.
• Examples: Kidney disease, liver disease, protein-losing enteropathy.
2. Increased Capillary Hydrostatic Pressure:
• Higher pressure at the end of capillaries pushes fluid out faster than it's
reabsorbed.
• This can happen due to heart problems, liver disease, obstructions, or even
prolonged standing.
3. Lymphatic Obstruction:
• Blocked lymphatic vessels prevent fluid drainage from tissues, leading to
localized swelling (lymphedema).
• Common causes include surgery, tumors, infections, or developmental issues.
1.Discuss the pathogenesis of edema.

4. Tissue Factors:
• In some cases, changes in tissue pressure or protein concentration within tissues
can contribute to fluid build-up.
• Examples: Loose tissues around eyes, inflammation increasing fluid protein content.
5. Increased Capillary Permeability:
• Damage to the capillary walls allows more protein to leak out, reducing blood's
pulling force and increasing fluid in tissues.
• Infections, toxins, allergic reactions, and anoxia are potential causes.
6. Sodium and water retention:
• Sodium and water retention can also contribute to oedema, often linked to hormonal
imbalances.
• Understanding the specific mechanism behind oedema is crucial for proper
diagnosis and treatment.
1.Discuss the pathogenesis of edema.

4. Tissue Factors:
• In some cases, changes in tissue pressure or protein concentration within tissues
can contribute to fluid build-up.
• Examples: Loose tissues around eyes, inflammation increasing fluid protein content.
5. Increased Capillary Permeability:
• Damage to the capillary walls allows more protein to leak out, reducing blood's
pulling force and increasing fluid in tissues.
• Infections, toxins, allergic reactions, and anoxia are potential causes.
6. Sodium and water retention:
• Sodium and water retention can also contribute to oedema, often linked to hormonal
imbalances.
• Understanding the specific mechanism behind oedema is crucial for proper
diagnosis and treatment.
1.Discuss the pathogenesis of edema.
1.Outline causes of edema.
Physiology
1.Outline the function of levels of CNS .
There are three levels of CNS.
1-Spinal cord Level
2-Lower brain or Subcortical Level.
3-Higher brain or Cortical Level.

1- Spinal Cord Level

We always think of the spinal cord as being only conduit for signals from
periphery of the body to the brain, but this is not true. Even after the spinal cord
has been cut in the high neck region spinal cord function still occur.
For instance, neuronal circuits in the cord can cause:
• Walking movements.
• Reflexes that withdraw portions of the body from painful object.
• Reflexes that stiffen the legs to support the body against gravity.
• Reflexes that control local blood vessels, gastrointestinal movements, urinary
excretion.
The upper levels of nervous system operate not by sending signals to the
periphery of the body but by sending to the control centers of the cord.
1.Outline the function of levels of CNS .
2- Lower Brain or Subcortical Level:
Many of the subconscious activities of the body are controlled in the lower areas
of the brain.(Medulla,Pons,Mesencephalon,Hypothalamus
Thalamus,Cerebellum,and Basal ganglia)
For example:
• Subconscious control of arterial pressure and respiration is achieved by
(Medulla,and Pons)
• Control equilibrium (cerebellum,Medulla,Pons,and Mesencephalon)
• Feeding reflexes,such as salivation and licking of the lips in response to the
taste of food controlled
by(Medulla,Pons,Mesencephalon,Amygdala,Hypothalamus)
• Control many emotional patterns such as anger, sexual response, reaction to
pain occur after destruction of much of cerebral cortex.
1.Outline the function of levels of CNS .

3- Higher Brain or Cortical Level.

• Cerebral cortex is an extremely large
memory storehouse.
• The cortex never function alone but
always with lower centers of the nervous
system. Without it the function of lower
of brain centers are imprecise.
• It is essential for most thought process.
• Each portion of nervous system
performs specific function but the cortex
that opens a world of stored information
for use by the mind.
1.Outline the function of levels of CNS .
Microbiology
1. Classify medical important gram-negative bacteria.
(Species) (Diseases)
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

The genus Neisseria contains two important human pathogens: Neisseria

meningitidis and Neisseria gonorrhoeae.
General Properties
-Gram-negative cocci called Neisseriae resemble paired kidney
beans.
-The outer membrane of Neisseriae contains endotoxins, which
are primarily lipooligosaccharide (LOS) compounds.
-Toxic trace metals and fatty acids present in some culture media
(such as blood agar plates) prevent it from growing. Therefore,
the inhibitors are rendered inactive by heating the blood on
"chocolate" agar to 80°C.
-Neisseriae have the cytochrome c enzyme, making them oxidase-
positive. This is a crucial diagnostic test in the lab where colonies
exposed to phenylenediamine turn purple or black due to the
enzyme's oxidation of the reagent.
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

General properties
-N. meningitidis (meningococcus) possesses a polysaccharide capsule that,
through inducing protective antibodies and acting as an antiphagocytic,
enhances its virulence. The antigenicity of the capsular polysaccharides of
meningococci allows for the division of the bacteria into at least 13 serologic
groups.
-Despite lacking a polysaccharide capsule, N. gonorrhoeae (gonococcus) is
classified into several serotypes according to the antigenicity of its pilus
protein. Chromosome rearrangement results in a notable antigenic variation in
the gonococcal pili. Three proteins make up the outer membrane of gonococci:
proteins I, II, and III.
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

Properties of the polysaccharide capsule

of the meningoccus:

1. Enhances virulence by its antiphagocytic action

2. Is the antigen that defines the serologic groups
3. Is the antigen detected in the spinal fluid of patients with
meningitis
4. Is the antigen in the vaccine
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.
1. Neisseria meningitidis Pathogenesis:
⁃ Humans are the only natural hosts for meningococci. The organisms are transmitted by airborne droplets

⁃ they colonize the membranes of the nasopharynx and become part of the transient flora of the upper
respiratory tract. From the nasopharynx, the organism can enter the bloodstream and spread to specific
sites, such as the meninges or joints, or be disseminated throughout the body (meningococcemia)

⁃ Carriers are usually asymptomatic

⁃ Two organisms cause more than 80% of cases of bacterial meningitis in infants older than 2 months of
age: Streptococcus pneumoniae and N. meningitidis.

⁃ meningococci are most likely to cause epidemics of meningitis.

⁃ is the most common cause in persons between the ages of 2 and 18 years
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.
Meningococci have three important virulence factors:

(1) A polysaccharide capsule that

enables the organism to resist
phagocytosis by polymorphonuclear
leukocytes (PMNs).
(2) Endotoxin, which causes fever, shock,
and other pathophysiologic changes (in
purified form, endotoxin can reproduce
many of the clinical manifestations of
meningococcemia).
(3) An immunoglobulin A (IgA) protease
that helps the bacteria attach to the
membranes of the upper respiratory
tract by cleaving secretory IgA
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

Clinical Findings
-The two most important manifestations of
disease are meningococcemia and meningitis.
-The most severe form of meningococcemia is the
life- threatening Waterhouse
–Friderichsen syndrome, which is characterized by
high fever, shock, widespread purpura,
disseminated intravascular coagulation,
thrombocytopenia, and adrenal insufficiency.
-Bacteremia can result in the seeding of many
organs, especially the meninges.
-The symptoms of meningococcal meningitis are
those of a typical bacterial meningitis, namely,
fever, headache, stiff neck, and an increased level
of PMNs in spinal fluid.
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.
Laboratory Diagnosis
•Primary laboratory procedures for diagnosing meningococcal
meningitis include smear and culture of blood and spinal fluid
samples.
•The organism grows best on chocolate agar incubated at 37°C in a
5% carbon dioxide
•Gram-negative cocci seen in a spinal fluid smear can indicate a
presumptive diagnosis.
•Neisseria can be identified if oxidase-positive colonies of gram-
negative diplococci are found.
•Differentiation between N-meningitidis and N-gonorrhoeae can be
made through sugar fermentation tests.
•Immunofluorescence and the latex agglutination test can also aid in
identification.
•Serum antibody tests are not helpful for clinical diagnosis.
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

Treatment
-Penicillin G is the treatment of meningococcal infections.
-A third- generation cephalosporin such as ceftriaxone can
also be used. Strains resistant to penicillin have rarely
emerged, but sulfonamide resistance is common

Prevention
-Chemoprophylaxis and immunization are used to prevent meningococcal disease.
-Rifampin or ciprofloxacin are preferred for prophylaxis due to their secretion into saliva.
-Meningococcal vaccines include capsular polysaccharides of groups A, C, and Y.
-There are two conjugate vaccines: Menactra, with polysaccharides conjugated to diphtheria
toxoid, and Menveo, with polysaccharides conjugated to a nontoxic mutant of diphtheria toxin.
-Menomune is an unconjugated vaccine.
-Conjugate vaccines generate higher antibody titers in children compared to the unconjugated
vaccine.
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

Neisseria gonorrhoeae Pathogenesis:

-Gonococci, like meningococci, cause disease only in humans. The organism is usually transmitted
sexually; newborns can be infected during birth.
-Gonorrhea is usually symptomatic in men but often asymptomatic in women. Genital tract infections are
the most common source of the organism, but anorectal and pharyngeal infections are important sources
as well.
-Pili constitute one of the most important virulence factors. (they mediate attachment to mucosal cell
surfaces and are antiphagocytic)
-Piliated gonococci are usually virulent, whereas nonpiliated strains are avirulent.
-Gonococci have no capsules.
-Two virulence factors in the cell wall are endotoxin (lipooligosaccharide, LOS) and the outer membrane
proteins.
-The main host defenses against gonococci are antibodies (IgA and IgG), complement, and neutrophils.
-Gonococci infect primarily the mucosal surfaces (e.g., the urethra and vagina
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

Clinical Findings
•Gonococci can cause localized infections in the genital tract or disseminated infections that
spread to various organs through the bloodstream.
•In men, gonorrhea primarily causes urethritis with dysuria and a purulent discharge, and
epididymitis may occur.
•In women, the infection primarily affects the endocervix, leading to a purulent vaginal discharge
and intermenstrual bleeding (cervicitis).
•The most common complication for women is an ascending infection of the uterine tubes, which
can result in infertility or ectopic pregnancy.
•Other infected sites include the anorectal area, throat, and eyes.
•In newborns, gonococcal infection acquired during birth can cause purulent conjunctivitis.
•Gonococcal conjunctivitis can also occur in adults through the transfer of organisms from the
genitals to the eyes.
•Other sexually transmitted infections like syphilis and nongonococcal urethritis caused by
Chlamydia trachomatis can coexist with gonorrhea.
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

Laboratory Diagnosis
-The diagnosis of urogenital infections depends on Gram staining and culture of the discharge
-nucleic acid amplification tests are widely used as screening tests
-In men, the finding of gram-negative diplococci within PMNs in a urethral discharge specimen is
sufficient for diagnosis
-In women, the use of the Gram stain alone can be difficult to interpret; therefore, cultures should be
done.
-Gram stains on cervical specimens can be falsely positive because of the presence of gram-negative
diplococci in the normal flora
-Specimens from mucosal sites, such as the urethra and cervix, are cultured on Thayer-Martin medium,
which is a chocolate agar containing antibiotics to suppress the normal flora.
-Specific identification of the gonococcus can be made either by its fermentation of glucose (but not
maltose) or by fluorescent-antibody staining.
-specimens from sterile sites, such as blood or joint fluid, can be cultured on chocolate agar without
antibiotics because there is no competing normal flora
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.

Treatment
Ceftriaxone is the treatment of choice in uncomplicated
gonococcal infections. Azithromycin or ciprofloxacin
should be used if the patient is allergic to penicillins or
cephalosporins

Prevention
The prevention of gonorrhea involves the use of condoms
and the prompt treatment of symptomatic patients and
their contacts.
Gonococcal conjunctivitis in newborns is prevented most
often by the use of erythromycin ointment. Silver nitrate
drops are used less frequently. No vaccine is available
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.
2. Outline general properties, clinical features, pathogenicity and lab diagnosis of
Neisseria.
Pharmacology
1. Discuss the adverse effects of adrenaline/ epinephrine and the
receptors.

Definition
Epinephrine is a catecholamine, produced
only by the adrenal glands from the amino acids
“phenylalanine and tyrosine” that acts as both a
neurotransmitter and hormone is also known as
adrenaline
1. Discuss the adverse effects of adrenaline/ epinephrine and the receptors.
Adverse effects of epinephrine.
• Epinephrine can produce adverse CNS effects that
include anxiety, fear, tension, headache, and tremor.
• It can trigger cardiac arrhythmias, particularly if the patient is receiving digoxin.
• Epinephrine can also induce pulmonary edema.
• Epinephrine may have enhanced cardiovascular actions in patients with hyperthyroidism,
and the dose must be reduced in these individuals.
• Patients with hyperthyroidism may have an increased production of adrenergic receptors in
the vasculature, leading to a hypersensitive response.
• Inhalation anaesthetics also sensitize the heart to the effects of epinephrine, which may
lead to tachycardia.
• Epinephrine increases the release of endogenous stores of glucose.
• In diabetic patients, dosages of insulin may have to be increased.
• Nonselective β-blockers prevent vasodilatory effects of epinephrine on β2 receptors, leaving
α receptor stimulation unopposed (This may lead to increased peripheral resistance and
increased blood pressure).
1. Discuss the adverse effects of adrenaline/ epinephrine and the receptors.
Thank you

PPT BY: Ibrahim Mukassabi