A 41 year old Asian female visiting the area comes to your clinic complaining of low energy, weight loss,

undigested food in her stool, hair loss, and cracking fingernails. Her history turns up Asian parents, her mother from the one of the islands of Vanuatu in Malanesia. One month before her visit at your practice she was diagnosed with a peptic ulcer likely caused by a Helicobacter pylori infection of her stomach. For this she has been prescribed antibiotics and Prilosec. She reports that her parents have no known problems. Physical examination of the woman revealed normal respiration, blood pressure, heart beat and rate, average height and weight, and no obvious physical abnormalities. Microbiology results show she is infected with staphylcoccus as well. Any ideas what could be causing her symptoms? Any staph related diseases that could match? Answer given by one of the furum members Q answered 3 years ago

The cracked fingernails and hair loss could be caused by a keratin-eating fungus like ringworm, but not by staph. Both could be caused by a cysteine deficiency; cysteine-cysteine disulfide bonds give keratin its integrity. A B12 deficiency would inhibit recycling of homocysteine to methionine, reducing the amount of methionine available for conversion to cysteine, and also inhibit conversion of methylmalonyl-CoA to succinyl-CoA, which would result in an increase in alpha-ketobutyrate and shift equilibrium away from cysteine+alpha-ketobutyrate and toward cystathionine, inhibiting cysteine production from methionine. Methionine is always the first amino acid translated, so methionine deficiency caused by inhibition of homocysteine --> methionine recycling would generally inhibit protein production, and would most acutely affect actively translating cells like those of the pancreas, which could account for the undigested food in the stool. B12 deficiency would cause methyl-tetrahydrofolate to accumulate and consequently deplete THF, which would account for the low energy and weight loss. It would also inhibit DNA replication, which would interfere with replacement of the gastric and intestinal mucosa, among others. The gastric ulcer then may not have been caused by H. pylori (though it's hard to argue against a successful treatment by antiobiotics). No idea why the staph is there, and that would seem to be central in a microbiology course, so likely this is all wrong.
1) Ribosomes are found in viruses? 2) The main consituent of a Gram positive cell wall is Peptidoglycan? 3) Bacterial cells have a large surface to volume ratio? 4) The cell wall may be a potential target for antibiotics? 5) The flagella allows substances in and out of the bacteria? 6) A plasmid is contained within the bacterial chromosome? 7) The space between the cytoplasmic membrane and the outer membrane is called the periplasm?

8) The outer membrane contains porins? 9) Bacteria are best measured in nanometers? 10) Pseudomonas bacteria have peritrichous flagella?

MCQs: Bacterial Cell Structure Part I: Answers

Answers 1) Ribosomes are found in viruses? False 2) The main consituent of a Gram positive cell wall is Peptidoglycan? True 3) Bacterial cells have a large surface to volume ratio? True 4) The cell wall may be a potential target for antibiotics? True 5) The flagella allows substances in and out of the bacteria? False, flagella are used for motility. 6) A plasmid is contained within the bacterial chromosome? False, a plasmid is a piece of extrachromosomal DNA. 7) The space between the cytoplasmic membrane and the outer membrane is called the periplasm? True 8) The outer membrane contains porins? True 9) Bacteria are best measured in nanometers? False, generally best measured in micrometers 10) Pseudomonas bacteria have peritrichous flagellae? False, pseudomonas bacteria have polar flagellae

MCQs:Culture Media: Answers

1) Louis Pasteur was the first person to use solid culture media? T/F False, this is historically attributed to Robert Koch, who initially used potatoes, before progressing to agar.

2) On MacConkey Agar, non-lactose fermenting bacteria will use peptone as their energy source instead.? T/F True, utilisation of peptone creates ammonia as a byproduct, turning the agar alakaline. 3) Streptococci grow well on Mannitol Salt Agar? T/F False, the high levels of salt in the agar favours the growth of staphylococci, but not streptococci. The presence of mannitol differentiates between Staphylococcus aureus which can ferment mannitol, from Coagulase Negative Staphylococci. 4) Hektoen Agar picks up the production of Hydrogen Sulphide by Salmonella species? T/F True, the agar contains thiosulphate, which produces a black precipitate in the presence of hydrogen sulphide (H2S). 5) Thayer-Martin Agar contains gentamicin, amongst other antibiotics? T/F False, gentamicin can actually be used as a treatment for Neiserria gonorrhoeae, so will not be in an agar used to select it out. 6) Amies Transport media contains high levels of carbon and nitrogen? T/F False. As it is a transport media, it contains no potential nutrient sources in order to prevent over-multiplication of bacteria. 7) The chocolate within chocolate agar provides the nutrients required for bacterial growth? T/F False. Chocolate Agar contains no chocolate.(I have tasted it and this is correct). The chocolate refers to the blood which has been heated to lyse the cells releasing growth factors like NAD and haemin, perfect for fastidious organisms like Haemophilus influenzae. 8) Buffered Charcoal Yeast Extract media is a good media for the isolation of Corynebacterium diptheriae? T/F False, BCYE agar is good for detection of Legionella pneumophilia. Corynebacterium diptheriae traditionally cultured on Hoyles medium. 9) Lactose Fermentors produce yellow colonies on CLED agar? T/F True. Cysteine Electrolyte Deficient Agar used in some laboratories for the identification of urinary organisms.

10) Lowenstein-Jenson slopes contain penicillin? T/F True, in order to suppress growth of bacteria thus selecting out mycobacteria

MCQs: Neisseria gonorrhoeae: Answers

1) The majority of infected females are asymptomatic? T/F True. Approxiamately 80% of females infected with Neisseria gonorrhoeae are asymptomatic. the converse is true for males where only 10% are asymptomatic. 2) Thayer-Martin Agar contains vancomycin? T/F True. Thayer-Martin agar is a selective media used for the isolation of Neisseria gonorrhoeae. It uses a combination of Vancomycin, Colistin and Nystatin (VCN) to select out N. gonorrhoeae. Modified Thayer Martin agar uses trimethoprim in addition. 3) Natural Infection with Neisseria gonorrhoeae gives long lasting immunity to further gonococcal infection. False: Little or no individual immunity gained from infection. Re-infection is common. 4) Neisseria gonorrhoeae grows poorly in 5% CO2? T/F False: the presence of CO2 (2-10%) is a pre-requisite for growth of Neisseria gonorrhoeae. 5) Neisseria gonorrhoeae usually infects squamous epithelial cells? T/F False: N. gonorrhoeae very much has a pre-dilection for infecting columnar epithelial cells. 6) Culture for Neisseria gonorrhoeae is just as sensitive as Nucleic Acid Amplification Tests (NAATs) for the diagnosis of Neisseria gonorrhoeae from extra-genital sites? T/F False: NAATs are more sensitive than culture for all sites for detection of N. gonorrhoeae. Specificity has historically been an issue for NAATs at extra-genital sites. This is now becoming less of an issue with newer generation molecular tests. However caution is still advised when diagnosing Neisseria gonorrhoeae from extra-genital tests with a molecular assay and confirmation with a different assay is usually still advised in this situation. 7) Neisseria Gonorrhoeae can occasionally cause Infective Endocarditis or Septic Arthritis? T/F

True: Should always be included in the differential diagnosis of both these clinical conditions and scientists should keep this possibility in mind. 8) Approximately 10% of Neisseria gonorhoeae strains are resistant to ciprofloxacin worldwide? T/F False: More like 30%+ these days. Big increase in the last 10 years. 9) Empirical treatment is generally with penicillin? T/F False: Penicillin resistance is 10-20% so empirical therapy these days is generally with intramuscular ceftriaxone. 10) High level resistance to ceftriaxone has been documented in Neisseria gonorrhoeae? T/F True: This is the big worry for the future and something which will need to be monitored very closely (see this article). There is a N. gonorrhoeae strain in Japan called H041 giving high level ceftriaxone resistance. Fortunately the strain seems to have low fitness and transmissability.

MCQs: Pasteurella multocida: Answers

1) Pasteurella multocida was discovered by Louis Pasteur? T/F True, in 1880, Pasteur discovered the bacterium as the cause of chicken cholera.

2) Pasteurella multocida can be a pathogen in unpasteurised milk? T/F False. Despite the name association, this is not a recognised epidemiological feature of Pasteurella infections.

3) Pasteurella multocida is a human pathogen only? T/F False. Can both colonise and cause infections in a range of mammals and birds.

4) Pasteurella multocida is oxidase and catalase positive, and does not grow on MacConkey agar? T/F True. Bacteria fitting the aforementioned criteria should be regarded as Pasteurella multocida until proven otherwise.

5) Pasteurella multocida tend to be pleomorphic in nature on the Gram Stain. True. Gram stain is of a Gram negative pleomorphic cocco-bacillus. It is non-motile.

6) Pasteurella multocida contains a polysaccheride capsule? T/F True. This acts as a virulence factor for the bacterium.

7) Pasteurella multocida can colonise the lower respiratory tract in humans? T/F True. Generally in patients with underlying architectural lung disease, it can both colonise and cause infection in the respiratory tract.

8) Pasteurella multocida responds well to clindamycin? T/F False. Clindamycin has little or no clinical activity against Pasteurella. Clinicians often use amoxycillin. Some clinicians use Amoxycillin/Clavulanic acid to give cover against anaerobes which are often there with Pasteurella multocida causing a poly-microbial infection.

9) Dogs are implicated more commonly than cats in human Pasteurella infections? T/F False. Although dog bites are more common than cat bites, cats are involved with the majority of clinical infections caused by Pasteurella. Cat bites are also responsible for a higher proportion of complex Pasteurella infections such as tenosynovitis, osteomyelitis, septic arthritis etc. Infection can also be caused by cat and dog licks.

10) Pasteurella multocida is a recognised cause of meningitis in humans? T/F True. However it is a relatively rare cause of meningitis and usually occurs at the extremes of age

MCQs: The Basic PCR Reaction: Answers

1) Taq Polymerase is a commonly used DNA polymerase in a PCR Reaction? T/F True: Other thermostable DNA polymerases can also be used such as Pfu polymerase which has a lower error rate when generating DNA strands. 2) DNA melting involves disrupting the covalent bonds between complementary DNA sequences? T/F False: DNA melting refers to the disrupting of hydrogen bonds between complementary DNA sequences. 3) Annealing of the primers occurs at the temperature of 50-65C? T/F True: Annealing temperature usually 3-5 degrees below the melting temperature of the prinmers used. 4) Primers generally consist of 200-300 nucleotides? T/F False: Primers usually consist of approximately 20 nucleotides. 5) In a PCR reaction, the DNA generated is itself used as a template for replication? T/F True: This is the whole reason and concept behind the exponential increase in target DNA strand. 6) Primers all have the same melting temperature? T/F False: Melting temperature of DNA strands, (including primers) dependent to some extent on the amount of Guanosine-Cytosine (GC) bonds, which generally have stronger bonds than Adenosine-Thymine (AT). Thus primers with higher GC content have higher melting temperatures.

7) The melting temperature is the temperature at which the DNA disintegrates into its separate nucleotides? T/F False: It is the temperature at which complementary DNA strands separate. 8) Urea may assist DNA denaturation? T/F True 9) The extension step usually occurs at a lower temperature than the annealing step? T/F False: The temperature in the PCR reaction is usually increased slightly to optimise this step. 10) PCR was invented by Sir Francis Crick? False: Crick involved with discovering the Double Helix structure of DNA. Discovery of PCR attributed to Kary Mullis in 1983.

Pseudomonas aeruginosa: Basic Bacteriology: Answers

1) 2) 3) 4) 5) 6) 7) 8) 9) Pseudomonas aeruginosa can infect plants as well as humans? True P. aeruginosa is motile by several peri-trichous flagellae? False Growth of Pseudomonas aeruginosa always requires the presence of oxygen? False When found in cystic fibrosis patients, it usually produces exopolysaccheride? True It has complex nutritional requirements? False It can often grow at 42 degrees C? True The pyoverdin pigment is thought to contain virulence factors? False It is unable to ferment lactose? True Its inherent antibiotic resistance are due to its environmental origins? True

10) It produces both Elastase and Alkaline Protease? True

MCQs: Staphylococcus aureus: Answers

1) Most people are colonised with Staphylococcus aureus? T/F False, most people colonised with coagulase negative staphylococci. Colonisation rate for Staphylococcus aureus probably 10-20% of the population. 2) The nuc gene is found in Methicillin Resistant Staphylococcus aureus? T/F True: The nuc gene found in all Staphylococcus aureus but is not the resistant determinant for MRSA, which is MecA, coding for the PBP2A protein. 3) Methicillin is a commonly used antibiotic in many parts of the world? T/F False: Essentially historical antibiotic, superseded by flucloxacillin, cloxacillin and dicloxacillin 4) Staphylococcus aureus can ferment mannitol? T/F True: This creates acid by-product and turns phenol indicator in Mannitol Salt Agar to yellow, giving yellow colonies. 5) Coagulase is not thought to be an important virulence factor for Staphylococcus aureus? T/F True: However useful for discriminating between Staphylococcus aureus and coagulase negative staphylococci 6) Staphylococcus aureus bacteraemia has a 30 day mortality of 15-20%? T/F True: One of the hishest mortality rates for any bacterial species. 7) Staphylococcus aureus can cause food poisoning? T/F True: Through the production of enterotoxins, usually with a short incubation period and short duration of symptoms. 8) Staphylococcus aureus is a motile organism? T/F False: As far as I am aware, it is non-motile. 9) Staphylococcus aureus can be intracellular in nasal epithelial cells? T/F

True: Explaining why Staphylococcus aureus colonisation can be difficult to eradicate, and the lack of decolonisation activity of antimicrobials with little intracellular activity, such as flucloxacillin. 10) Staphylococcus aureus is a common contaminant in blood cultures? T/F False: Most of the time when found in blood cultures, is pathogenic. Occasionally a contaminant. If only cultured from one bottle after a significant time period (ie >15hrs), this can be a pointer towards it being a contaminant.

MCQs: Clinically Important Anaerobes: Answers

1) Clostridium difficile infection responds well to intra-venous vancomycin? T/F False: Although vancomycin has good in-vitro activity against Clostridium difficile, it is too big a molecule to cross the intestinal epithelium. Therefore Intra-venous vancomycin has no effect on Clostridium difficile. Oral vancomycin (or metronidazole) is a better option. 2) Propionibacterium acnes is a common cause of infections in prosthetic shoulder joints? T/F True: This is well recognised, however it is not so clear why shoulders in preference to knees or joints. It may be because of a higher load of Propionibacterium in the upper part of the body. 3) Fusobacterium nucleatum is more pathogenic than Fusobacterium necrophorum? T/F False: Fusobacterium necrophorum is more pathogenic than Fusobacterium nucleatum. Fusobacterium necrophorum can cause severe infections such as Lemierres syndrome and unlike Fusobacterium nucleatum, tends not to colonise the oropharynx. 4) When Bacteroides fragilis is isolated from blood cultures, it often indicates intra-abdominal pathology? T/F True: In this setting often indicates the presence of an intra-abdominal collection, or occasionally perforation. 5) Lactobacillus is the dominant bacterium in a menstruating female? T/F True: There is a close link between the presence of estrogen and Lactobacillus predominance in the female genital tract. This predominance is usually absent in the pre-pubertal and postmenopausal period.

6) Actinomyces israelii is a facultative anaerobe? T/F False: Actomyces israellii is a strict anaerobe. 7) Prevotella species commonly produce beta-lactamase? T/F True: This may have implications for treatment of infections caused by Prevotella. 8) Peptostreptococcus can occasionally be a contaminant in blood cultures. T/F True: Peptostreptococcus can colonise skin and therefore can be a blood culture contaminant. 9) Veillonella is a Gram negative bacillus. T/F False: Usually a Gram negative coccus. 10) If anaerobic culture is negative then anaerobic antibiotic cover can be discontinued? T/F False: Anaerobic culture is not sensitive enough to allow this luxury. Whether anaerobic cover can be stopped is very much a clinical judgement

MCQs: Helicobacter pylori: Answers

1) Helicobacter pylori was discovered by Louis Pasteur? T/F False: Discovered in 1982 by Australian scientists Barry Marshall and Robin Warren.

2) H. pylori is increasing in prevalence in developed countries? T/F False: Although H. pylori has one of the highest prevalences of any infectious disease in the world (40-50%), its prevalence is now decreasing in developed countries (10-25%)

3) H. pylori is a micro-aerophilic Gram negative bacterium? T/F True. It is also spiral shaped, although not officially a spirochaete.

4) H. pylori survives in the acidic environment of the stomach by producing urea? T/F False: It produces a urease, which breaks down urea found in the stomach to carbon dioxide and ammonia. The ammonia neutralises the surrounding acid.

5) The stool antigen assay for H. pylori is more specific at picking up active disease than H. pylori serology? T/F True: H. pylori antibodies can be present in past treated infection so may not necessarily represent current active infection.

6) Culture of H. pylori from a gastric biopsy specimen is the most sensitive method for detecting the bacterium? T/F False: H.pylori is a relatively fastidious organism so false negatives on culture are not unusual.

7) H.pylori produces a hypertrophic gastritis? T/F False: It produces an atrophic gastritis.

8) H. pylori causes about 10% of duodenal ulcers? T/F False: It causes 80-90% of duodenal ulcers.

9) Proton pump inhibitors can give false negative results on a urea breath test? T/F True: Probably because less urease production is needed by the bacteria in a less acidic environment.

10) H. pylori is always susceptible to metronidazole? T/F

False: Resistance rates of 10-20% not unusual.

Data Interpretation: Case number 2: Answers

A 75 year old man presents to hospital with a cerebro-vascular accident. As part of his routine laboratory investigations syphilis serology is performed. The results show a positive TPPA titre of 1:128. RPR testing is negative.

Question 1: Could this TPPA result be falsely positive? It could be, but very unlikely. Specific treponemal antibody tests such as TPPA tend not to give false positive results. On the rare occasion that they do, it is usually due to laboratory error or an autoimmune condition In contrast non-specific treponemal antibody tests such as RPR or VDRL are quite prone to giving low titre false positive results. False positive RPR or VDRL results can be caused by variety of acute and chronic diseases, such as mixed connective tissue disease, autoimmune disease, diabetes mellitus, alcoholic cirrhosis, viral infections and pregnancy.

Question 2: What clinical scenarios could give rise to this serological picture? Quite a few

Probably the most common reason for this picture is past treated syphilis. However late latent untreated infection can also give this picture, as in such cases the VDRL/RPR antibody can fall away to undetectable limits.

In persons from countries where other treponemal infections such as yaws (eg Pacific, Carribean), pinta (Central America) or bejel are endemic, then infection with these conditions can give positive treponemal antibody results.

The other possible scenario is early primary syphilis infection. One would have to say that this unlikley, but not impossible in a 75 year old!

MCQs: VZV laboratory testing: Answers

1) VZV IgM serology is a sensitive means of picking up acute infection. T/F False: Several false negative results occur from VZV IgM testing. Many labs no longer offer the assay. 2) Most people who dont have a clinical history of chickenpox have negative VZV IgG on laboratory testing? T/F False: Most people (80%+) who have no clinical history of chickenpox actually have VZV IgG antibodies on lab testing and are thus immune. 3) IgG seroconversion can more reliably be detected after VZV vaccination as opposed to natural infection? T/F False: Natural infection produces the strongest IgG response. False negative IgG results occasionally produced after vaccination. 4) PCR can potentially be used to discriminate between vaccination and wild type strains of VZV? T/F True: PCR genotyping can potentially discriminate if the assay is designed for this purpose. 5) Cotton is a better material than polyester at picking up VZV virus? T/F False: Polyester is a better material than cotton and is recommended in viral PCR swabs. 6) When the rash has crusted over, the PCR is ineffective at picking up VZV? T/F False: Crusts contain high levels of virus and OCR is usually effective at testing this specimen type. 7) PCR is an effective method of distinguishing between a chickenpox and a shingles rash? T/F False: It is the same virus, so PCR will not discriminate between the two clinical entities. 8) VZV Immunofluorescence is commonly used in laboratories to make the diagnosis of chickenpox? T/F False: It certainly can be used, but in my experience, is certainly not common amongst routine diagnostic laboratories for the diagnosis of VZV.

9) VZV is able to be cultured on cell lines? T/F True: but with poor sensitivity. Viralculture now rarely used to make a diahnosis of VZV in diagnostic laboratories. 10) Electron microscopy can discriminate between VZV and Herpes Simplex Virus (HSV)? T/F False: The two viruses look the same on electron microscopy.

MCQs:Hepatitis B serology: Answers

1) Most positive HBsAg results picked up on ante-natal screening represent chronic infection? T/F True, probably more than 95% of such results represent chronic infection, most of whom have probably had the infection for years or even since birth. 2) IgM Anti-HBc can be used to differentiate acute from chronic Hepatitis B infection? T/F True, but in my opinion only occasionally needed to confirm acute infection in someone who is either symptomatic or has had a recent contact with Hepatitis B. For the majority of cases, chronic infection can be assumed. 3) A patient with negative HBeAg will always have a low HBV viral load? T/F False. Hepatitis B viruses containing pre-core mutants may be HBeAg -ve but still have high HBV DNA levels. 4) Anti-HBc (total) is usually negative in chronic Hepatitis B infection? T/F False: Anti-HBc should always be positive in chronic Hepatitis B infection. If it is negative, it should prompt you to look at the validity of your HBsAg result. 5) A patient who has had acute Hepatitis B infection in the past and has cleared the virus, will have positive anti-HBc and anti-HBs? T/F True 6) Hepatitis B vaccination induces a strong anti-HBc response? T/F False: Hepatitis B vaccination does not produce anti-HBc so thus differentiates it from immunity due to resolved acute infection (as in Q5)

7) The incubation period after exposure to Hepatitis B virus until symptoms appear is approximately 1 week? T/F False: Can be anything between a few weeks to a few months. 8) Expectant mothers who are HBsAg +ve may be candidates for anti-viral treatment? T/F True: Expectant mothers with abnormal LFTs, HBeAg +ve, or with high HBV viral loads may all be candidates for anti-viral treatment during pregnancy. See this algorhythm 9) Patients who are anti-HBc +ve, but negative for HBsAg and anti-HBs. This can represent a range of scenarios, the most common being resolved acute infection? T/F True: See this article 10) Patients who are HBsAg +ve and also anti-HBe +ve are not infective to others? T/F False. Patients who are HBsAg +ve are potentially infective to others regardless of their other serology results.

Data Interpretation Case Number 4: Answers

A mother tests HBsAg +ve on antenatal screening.

1) What other blood tests are indicated here in light of this result? Anti-HBs Abs Anti-HB core Abs HepBeAg

HCV Abs HIV serology.

HBV viral load (guidelines differ, but pregnant women with high viral loads may be candidates for anti-viral agents in the third trimester to reduce the chances of mother to child transmission (MTCT)) Liver function tests (LFTs)

(Unless the mother is acutely unwell there is little point in performing anti-HBcore IgM Abs. A positive screening test is almost always going to indicate chronic Hepatitis B infection)

2) What should all neonates born to HBsAg +ve mothers receive? Regardless of whether the mother received anti-virals, all neonates born to HBsAg +ve mothers should receive Hep B immunisation (1st dose at birth) and Hepatitis B immunoglobulin. Both passive and active immunisation together reduces the risk of MTCT by 90%.

3) What laboratory tests should be performed on the baby? Guidelines differ with regards to this but my preference is for HBsAg and anti-HBsAb at 9-12 months. At this age confusing maternal antibodies should be gone and a clear interpretation can be made on the lab results.

Data Interpretation: Case Number 3: Answers

A 20 year old presents with a 72 hour history of headache, photophobia and fever. On examination he is alert and orientated and has mild neck stiffness. There are no focal neurological signs. He has no significant past medical history. He has no risk factors for HIV nor does he have any history of travel to tropical areas. A CT scan of his head is normal. A lumbar puncture is performed and a CSF sample is taken. The initial CSF results are as follows:

Clear and colourless macroscopically White cell count: 85 x 10^6/l, Differential 99% lymphocytes. Red cell count: 14 x 10^6/l Protein 0.7 g/l Glucose 4.2 mmol/l (serum glucose 6.5 mmol/l) Gram Stain: No organisms seen

The following morning he is feeling a bit better, with supportive and symptomatic treatment alone. 1) What is the likely cause of this young mans illness? Common things are common, and this presentation is most likely to represent a viral meningitis caused by an enterovirus. In most parts of the world, enteroviruses cause approximately 75% of all cases of lymphocytic meningitis. In our laboratory this profile above would easily be the most typical CSF picture that we see.

2) What further testing should be undertaken on the CSF sample? There is NO right or wrong answer to this question. The answer depends on many factors. e.g. duration and persistence of symptoms, severity of symptoms, risk factors for particular diseases, whether treatment is available, turnaround time and cost of testing. In our institution, such patients often end up getting Enterovirus and Herpes Simplex Virus (HSV) PCR testing. Given that in this particular case, the patient is getting better within 24 hours (as they most often do) there is an argument for doing no further testing at all. I can imagine it would be frustrating sweating over a CSF PCR on a patient, only to come across the patient later that day going about their normal business, having fully recovered from his illness and discharged from hospital. (These tests need to be real-time to have any significant impact) If the patient is not getting better, could consider testing the CSF for CMV, EBV, VZV, HHV6, mumps, measles, influenza, LCMV (Lymphocytic Chorio-Meningitis Virus). Consider testing for arboviruses depending on what part of the world you live in. Consider a serum HIV test. Consider spirochaetes such as Lyme disease and leptospirosis. Consider other non-viral pathogens such as mycobacteria, fungi and rickettsia. The list is endless! (and these are only the main infectious causes that are being considered, not to mention non-infectious causes of CSF lymphocytosis. This is where the CSF volume comes into play and often more CSF is required from the patient

for extended testing. Clinical Microbiologists like myself can also occasionally be useful for rationalising extended testing!

A 20 week old pregnant woman presents to her GP with a 2 week history of general malaise, sore throat and swollen glands in her neck. Her GP orders Cytomegalovirus (CMV) serology. Her CMV IgM is low reactive and CMV IgG is moderately reactive. 1) Why is the diagnosis of CMV infection in pregnancy important? Because of the risk of intra-uterine transmission of the virus leading to congenital CMV infection. 2)What other tests could/should the GP have requested? Given that the patient is pregnant I think the full range of Infectious Monocleosis like illnesses should be screened for here, EBV, CMV, Toxoplasmosis and HIV. I would also do a Full Blood Count to see whether there is a relative lymphocytosis with atypical lymphocytes present. There is also an argument for Liver Function Tests (LFTs) but where do you stop. 3) How can the laboratory clarify whether this is a CMV infection occuring during pregnancy?

As the CMV IgM is low reactive, I would recommend repeating it. It is also important to check what the EBV(VCA) IgM is to exclude a cross-reaction.

Ante-natal booking bloods should have been taken at 12-14 weeks gestation and serum should be stored. Important to go back and test this stored serum to see if an IgG seroconversion can be demonstrated.

Also worthwhile taking current serum and performing CMV IgG avidity testing. I the avidity is low then this indicates more recent infection and thus the probability of the CMV infection having occured during pregnancy.

Requesting repeat CMV serology from the patient in 2-4 weeks looking for any change in CMV IgM and IgG titres