MICP REVIEWER
VIRAL
BACTERIAL
Laboratory Diagnosis. Demonstration of acid-fast bacilli (AFB) in sputum specimens provides a rapid, presumptive
diagnosis of tuberculosis. Isolation of M. tuberculosis on Löwenstein-Jensen or Middlebrook culture media takes about
3–6 weeks because of the organism’s long generation time (about 18–24 hours). A variety of more rapid techniques are
available for isolation and identification of M. tuberculosis, including automated and semi automated instruments,
molecular diagnostic procedures, and gas–liquid chromatography. Susceptibility testing should be performed as soon as
possible, because many strains of M. tuberculosis are multidrug resistant. Infected patients show a positive delayed
hypersensitivity skin test (the Mantoux purified protein derivative [PPD] tuberculin skin test), and pulmonary tubercles
may be seen on chest radiographs.
FUNGAL
SKIN
Dermatophytoses are also known as tinea (ringworm) infections and dermatomycoses.
Diseases.
Some of the dermatomycoses cause only limited irritation, scaling, and redness. Others cause itching, swelling, blisters,
and severe scaling.
Patient Care.
Use Standard Precautions.
Pathogens.
Dermatomycoses are caused by various filamentous fungi (moulds), collectively referred to as dermatophytes. Examples
include species of Microsporum, Epidermophyton, and Trichophyton.
Reservoirs and Mode of Transmission.
Infected humans and animals and soil serve as reservoirs. Transmission is by direct or indirect contact with lesions of
humans or animals; or contact with contaminated floors, shower stalls, or locker room benches; barbers’ clippers, combs,
and hairbrushes; or clothing.
Laboratory Diagnosis.
Microscopic examination of potassium hydroxide (KOH) preparations of skin scrapings or hair or nail clippings can reveal
the presence of fungal hyphae. Dermatophytes can be cultured on various media, including Sabouraud dextrose agar.
Moulds are identified using a combination of macroscopic and microscopic observations.
ORAL REGION
Thrush
Disease.
Thrush is a yeast infection of the oral cavity. It is common in infants, elderly patients, and immunosuppressed individuals.
White, creamy patches occur on the tongue, mucous membranes, and the corners of the mouth. Thrush can be a
manifestation of disseminated Candida infection (candidiasis). Candida albicans is the yeast and the fungus most
commonly isolated from clinical specimens— sometimes isolated as a pathogen and sometimes isolated as a
contaminant.
Pathogens.
The yeast, C. albicans and related species.
Reservoir and Mode of Transmission.
Infected humans serve as reservoirs. Transmission occurs by contact with secretions or excretions of mouth, skin,
vagina, or feces of patients or carriers; also by passage from mother to neonate during childbirth and by endogenous
spread (i.e., from one area of the body to another).
Laboratory Diagnosis.
Thrush can be diagnosed by observation of yeast cells and pseudohyphae (strings of elongated buds) in microscopic
examination of wet mounts, and by culture confirmation
GENITOURINARY SYSTEM
Yeast Vaginitis
Disease.
The three most common causes of vaginitis in the United States, each causing about one third of the cases, are C.
albicans (a yeast), Trichomonas vaginalis (a protozoan), and a mixture of bacteria (including bacteria in the genera
Mobiluncus and Gardnerella). A saline wet mount preparation is usually used to diagnose vaginitis. Typical symptoms of
yeast vaginitis are vulvar pruritus (itching), a burning sensation, dysuria, and a white discharge. Vulvar erythema
(redness) and rash sometimes occur.
Pathogens.
The yeast, C. albicans, causes about 85% to 90% of yeast vaginitis; other Candida spp. can also cause this disease.
Reservoir and Mode of Transmission.
Infected humans serve as reservoirs. Transmission occurs by contact with secretions or excretions of mouth, skin,
vagina, or feces of patients or carriers; also by passage from mother to neonate during childbirth and by endogenous
spread (i.e., from one area of the body to another).
Laboratory Diagnosis.
Yeast vaginitis can be diagnosed by microscopic examination of a saline wet mount of vaginal discharge material, in
which yeasts and hyphae may be observed. The vaginal discharge material should also be cultured. Candida spp. grow
well on blood agar and Sabouraud dextrose agar. Candida spp. can usually be identified using a commercial yeast
identification minisystem. It is important to keep in mind that the vaginal microflora of up to 25% of healthy women can
contain Candida spp.
CENTRAL NERVOUS SYSTEM
Cryptococcosis (Cryptococcal Meningitis)
Disease.
Cryptococcosis starts as a lung infection, but spreads via the bloodstream to the brain. It usually presents as a subacute
or chronic meningitis. Infection of the lungs, kidneys, prostate, skin, and bone may also occur. Cryptococcosis is a
common infection in acquired immunodeficiency syndrome (AIDS) patients.
Patient Care.
Use Standard Precautions for hospitalized patients.
Pathogens.
Cryptococcosis can be caused by three subspecies of C. neoformans, an encapsulated yeast (refer back to Fig. 5-8 in
Chapter 5). The capsule enables C. neoformans to adhere to mucosal surfaces and avoid phagocytosis by white blood
cells.
Reservoirs and Modes of Transmission.
Reservoirs include pigeon nests; pigeon, chicken, turkey, and bat droppings; and soil contaminated with bird droppings.
Growth of C. neoformans is stimulated by the alkaline pH and high nitrogen content of bird droppings. Transmission
occurs by inhalation of yeasts, often projected into the air by sweeping or excavation. Cryptococcus is not transmitted
from person to person or animal to person.
Laboratory Diagnosis.
Cryptococcal meningitis is often diagnosed by observing encapsulated, budding yeasts in cerebrospinal fluid specimens
examined by an India ink preparation. Yeasts may also be observed in sputum, urine, and pus examined by an India ink
preparation or Gram stain. C. neoformans can be cultured on routine media used in the Mycology Section. A sensitive
cryptococcal antigen detection test is available.
PARASITIC
PROTOZOAL
SKIN
Leishmaniasis
Disease.
There are three forms of leishmaniasis: cutaneous, mucocutaneous (or mucosal), and visceral. The cutaneous form
starts with a papule that enlarges into a craterlike ulcer. Individual ulcers may coalesce, causing severe tissue destruction
and disfigurement. Visceral leishmaniasis, also known as kala-azar, is characterized by fever, enlarged liver and spleen,
lymphadenopathy, anemia, leukopenia, and progressive emaciation and weakness. Death may result in untreated cases.
Patient Care.
Use Standard Precautions for hospitalized patients.
Geographic Occurrence.
Leishmaniasis occurs in many regions of the world, including Pakistan, India, China, the Middle East, Africa, South and
Central America, and Mexico. Cases have also occurred in south central Texas. It is estimated that between 1.5 and 2
million people have leishmaniasis and that about 57,000 people die each year of the disease
Parasites.
Leishmaniasis is caused by various species of flagellated protozoa in the genus Leishmania. The nonmotile, intracellular
form of the parasite is called an amastigote. The motile, extracellular form of the parasite is called a promastigote.
Reservoirs and Mode of Transmission.
Reservoirs include infected humans, domestic dogs, and various wild animals. Leishmaniasis is principally a zoonosis
and is usually transmitted via the bite of an infected sand fly. Transmission by blood transfusion and person-to-person
contact have been reported.
Laboratory Diagnosis.
Diagnosis of cutaneous and mucocutaneous leishmaniasis is made by microscopic identification of the amastigote form
in stained preparations from lesions or by culture of the extracellular promastigote form on suitable media. Culture is
rarely performed in clinical microbiology laboratories. In stained preparations, amastigotes are seen within macrophages
and close to disrupted cells. An intradermal test, called the Montenegro test, and immunodiagnostic and molecular
diagnostic procedures are also available. In the Montenegro test, an antigen derived from promastigotes is injected into
the skin.
GENITOURINARY
Trichomoniasis
Disease.
Trichomoniasis is a sexually transmitted protozoal disease affecting both men and women. The disease is usually
symptomatic in women, causing vaginitis with a profuse, thin, foamy, malodorous, greenish-yellowish discharge. It has
been estimated that trichomoniasis accounts for approximately one third of the cases of vaginitis in the United States
(another third is caused by Candida albicans, and another third by bacteria). In women, trichomoniasis may also present
as urethritis or cystitis. Although rarely symptomatic in men, trichomoniasis may lead to prostatitis, urethritis, or infection
of the seminal vesicles. Persons with trichomoniasis often also have other sexually transmitted diseases, especially
gonorrhea.
Patient Care.
Use Standard Precautions.
Geographic Occurrence.
Trichomoniasis occurs worldwide.
Parasite.
Trichomoniasis is caused by Trichomonas vaginalis, a flagellate.
Reservoirs and Mode of Transmission.
Infected humans serve as reservoirs. Transmission occurs by direct contact with vaginal and urethral discharges of
infected people during sexual Intercourse. Because this organism exists only in the fragile trophozoite stage (there is no
cyst stage), it cannot survive very long outside the human body.
Laboratory Diagnosis.
Vaginitis caused by T. vaginalis can be diagnosed by performing a saline wet mount examination of freshly collected
vaginal discharge material and observing the motile trophozoites. Culture procedures are also available, but are rarely
performed in clinical microbiology laboratories. T. vaginalis trophozoites are sometimes seen in urine and Papanicolaou
(Pap) smears. Diagnosis of trichomoniasis in men can be accomplished by performing a saline wet mount of urethral
discharge material or prostatic secretions.
