True False: Feedback

1 A 25-year-old female presented in the emergency room with an acute urethral discharge of two days duration.
The
image to the right shows the Gram stained smear that was obtained. Many polymorphonuclear leukocytes and
intracellular and extracellular gram-negative diplococci were observed. Based on the clinical history and the Gram stain
observation, a diagnosis of gonorrhea can be made.The correct answer is highlighted below
True
False
FeedbackAlthough the clinical history and Gram stain findings are suggestive of acute gonorrhea, organisms that
resemble N. gonorrhoeae may reside in the female genital tract. Look-alike organisms include Acinetobacter
baumanii and Capnocytophaga ochracea, which are both oxidase negative. Two other look-alikes, Kingella
kingae and Moraxella catarrhalis, are oxidase positive and may be difficult to distinguish from N. gonorrhoeae which
also is oxidase positive(source of the specimen is also a consideration). Therefore, culture is required in females to
recover and identify the presence of N. gonorrhoeae.
Continue to the next page
2 The positive oxidase reaction as shown in the image (yellow arrow) rules out which of the following two look-alike
organisms of N. gonorrhoeae? (Choose all that apply)
The correct answers are highlighted below
Moraxella catarrhalis
Capnocytophaga ochracea
Acinetobacter baumannii
Kingella kingae
Feedback
A positive spot oxidase reaction is helpful in ruling out the oxidase-negative strains of Capnocytophaga
ochracea andAcinetobacter baumannii, which in Gram stain may simulate Neisseria gonorrhoeae. Both
Moraxella catarrhalis and Kingella kingae are oxidase positive; therefore, other tests must be used to differentiate these
two species.
The Superoxol Test
Hover over the image to zoom in.

Superoxol is an additional spot test that may be helpful in the presumptive identification of N. gonorrhoeae.
Superoxol is 30% hydrogen peroxide, in contrast to the 3% solution that is used in the catalase test.
Other Neisseria species and Moraxella catarrhalis are either negative for this test or give a weak, delayed
reaction.
3 The carbohydrate utilization reaction seen in the QuadFerm system shown in the image provides a definitive
identification of N. gonorrhoeae.
The correct answer is highlighted below
True
False
Feedback
Under the conditions of the question, the answer is false. In clinical cases, the collective observations of gramnegative intracellular diplococci on a Gram stain, growth on Modified Thayer-Martin (MTM) agar, positive
oxidase and superoxol reactions, and the selective fermentation of glucose as seen here would be considered
"definitive". In cases of suspected sexual abuse, positive results of an additional definitive monoclonal antibody
or nucleic acid probe test would be required to make a courtroom testimony fool-proof. (Note: the QuadFerm
system no longer on the market; however, the same principle applies to any system that determines patterns of
carbohydrate utilization).
4 Acute gonorrhea is the most common cause of septic arthritis in patients under 30 years of age.
True
False
Feedback
According to the paper abstracted from Curcurull and Espinosa, septic arthritis in patients under the age of 30
is most commonly associated with acute gonorrhea. It is also of interest that these authors also found that
disseminated disease is the most common complication of acute gonorrhea, occurring in 0.5% - 3% of all cases.
5 The recovery of an oxidase-positive, gram-negative diplococcus that tests direct flourescent antibody (DFA)
non-reactive should be tested by alternative methods when establishing a fool-proof diagnosis of gonorrhea.
You answered the question correctly.
True
False
Feedback
In the paper by Smith, et al, up to 2.5% of isolates of N. gonorrhoeae will test DFA non-reactive. Therefore, in
cases with far reaching implications, such as in establishing sexual abuse, at least two definitive tests must be
performed to confirm the identification. The lesson from this paper is that in about 2.5% of cases, a negative
DFA test will not provide the correct answer, and an additional confirmatory test is required.
6 The Gram stain report to be issued based on the microscopic characteristics seen in the image on the right
would most correctly be, "many WBC with..." (Choose the BEST response)
You answered the question incorrectly.
gram positive cocci.
gram positive cocci in pairs.
gram positive rods.

gram negative cocci.
Feedback
A Gram stain report of gram-positive cocci in pairs would be most appropriate. Although gram-positive cocci is
not incorrect, it is often helpful to the referring physician to know more specifically the morphology and
arrangement of the cells, as such information may fit in with the clinical picture leading to more exacting
empiric antibiotic therapy. This Gram stain description is most consistent with that of S. pneumoniae. Cells may
also arrange in short chains simulating the Enterococci. Although the cells of S. pneumoniae may elongate and
become lancet-shaped, they rarely would be confused with true bacilli. The blue-staining of the cells makes
them gram-positive, making the last response incorrect.
7 Based on the Gram stain morphology observed in the previous image, the possible presumptive
identifications might include "gram-positive cocci consistent with... (Choose all that apply)
Staphylococcus aureus
Enterococcus species
Streptococcus pneumoniae
"Diphtheroids"
Feedback
Although the blue-staining, gram-positive cocci in pairs, each with a distinct lancet-shape is most consistent
with S. pneumoniae, some strains of Enterococcus species may have "look-alike" gram stain features, and
additional tests must be performed to confirm the identification.
8 The patient was admitted to the hospital. The sputum specimen was inoculated to sheep blood agar. Based
on the colony morphology and the alpha hemolysis seen in the image to the right, the most likely identification
is:
viridans streptococcus
Streptococcus pyogenes
Streptococcus agalactiae
Feedback
Assuming an alpha hemolytic reaction (not well seen in the image), viridans streptococcus and S.
pneumoniae are the two possible responses. However, these colonies are far too mucoid for viridans
streptococci; therefore, S. pneumoniae is the most likely choice. Also, the colonies are much too large and the
hemolytic reaction is wrong for S. pyogenes or S. agalactiae.
9 The zone of inhibition around the disk shown in the image has been measured at 23 mm. Based on this result,
you should:
Report oxacillin-susceptible
Repeat the test
Check the potency of the disk
Perform a minimum inhibitory concentration (MIC) test on the isolate
Feedback
According to the current Clinical and Laboratory Standards Institute(CLSI, formerly NCCLS) guidelines, an isolate
of S. pneumoniae is considered to be susceptible if the zone of inhibition around the 1ug oxacillin disk is > 20
mm. Thus, in this case, the isolate is oxacillin susceptible and penicillin can be administered. A follow-up MIC
should be performed only if the zone of inhibition measures <19 mm as the degree of resistance cannot be
determined.
10 The oxacillin screen test alone is not sufficient for determining the susceptibility to penicillin forS.
pneumoniae isolates recovered from cerebrospinal fluid (CSF).
True
False
Feedback
The oxacillin screening test is not recommended for isolates of S. pneumoniae from CSF; the minimum inhibitory
concentration (MIC) test should be performed. In some laboratories, direct MIC testing is done for all clinically
important S. pneumoniae isolates regardless of source, thereby providing a definitive result one day sooner.
11Minimum inhibitory concentration (MIC) susceptibility tests should be performed against other beta lactam
antibiotics on important S. pneumoniae isolates from blood cultures and other sterile body fluids when a MIC for
penicillin is performed.
True
False
Feedback
The MIC susceptibility test results obtained for penicillin also are predictive for ampicillin, cefotaxime, imipenem,
and other beta-lactam antibiotics, precluding the necessity for performing specific tests against these drugs.
12 Streptococcus pnemoniae is the most common cause of fatal community-acquired pneumonia.

True
False
Feedback
According to the paper by Jedrzejas, S. pneumoniae indeed is the cause of most fatal cases of communityacquired pneumonia.
13 Middle ear damage in cases of S. pneumoniae infections are caused primarily by the: (Choose all that
apply)
Action of outer membrane proteins
Production of hyaluronidases
Release of cell wall cytokines
Production of pneumolysin
Feedback
According to the study published by Tuomanen, the release of cell wall cytokines, with the subsequent influx of
polymorphonuclear leukocytes, is a primary cause of middle ear damage in pneumococcal infections. 14
Pneumolysin is a protein product of the pneumococci that both arrests ciliary motion, compromising bacterial
clearance, and directly activates an acute inflammatory response through the classic complement pathway.
Outer membrane proteins are virulence factors for gram-negative bacteria; and the production of
hyaluronidase is a virulence factor produced by group A beta hemolytic streptococci.
15 Pneumococcal vaccine is particularly effective in children less than two years of age.
True
False
Feedback
According to the paper by Jedrzejas, just the opposite is true. Pneumococcal vaccine is most effective in older
individuals, who can still mount an antibody response, although somewhat compromised in the elderly.
Antibody responses are minimal or absent in the under 2-year-old age group of children.
16 the colonies shown in the blood (BAP) agar (upper) and MacConkey (MAC) agar (lower) biplate are a 24
hour growth from an aerobic blood culture bottle that became positive at 12 hours after inoculation. The
appearance of the colonies on MAC agar rules out the following two bacterial species:
Pseudomonas aeruginosa
Klebsiella pneumoniae
Escherichia coli
Feedback
Although Pseudomonas aeruginosa may produce mucoid colonies on MAC agar, it does not ferment lactose,
which is evident from the pink pigmentation of the colonies. S. pneumoniae colonies may be mucoid, but
cannot grow in the presence of the bile salts and the crystal violet dye contained in MAC agar. Both K.
pneumoniae and E. coli can produce mucoid, lactose fermenting colonies on MAC agar. The colonies of E.
coli, however, tend to be dry and the surrounding medium also tends to turn pink or red from strong lactose
fermentation. Thus, the colonies seen here are most consitent with K. pneumoniae
17 The reactions seen in the portion of the API strip shown in the photograph, effectively rules out Escherichia
coli.
True
False
Feedback
The positive reactions for sodium citrate, urea (weak), and Voges Proskauer are negative for all strains
of Escherichia coli. Most strains of E. coli are ONPG and indole positive, opposite to that seen here. Thus, a quick
assessment of these reactions quickly eliminates E. coli from the differential identification.
18 solates of Escherichia coli, Klebsiella pneumoniae, K. oxytoca and clinically significant isolates of Proteus
mirabilis may possess extended-spectrum beta-lactamase (ESBL) activity.
True
False
Feedback
These organisms are known to possess ESBL activity. These enzymes have the ability to hydrolyze thirdgeneration cephalosporins and aztreonam, but are inhibited by clavulanic acid. ESBL-producing organisms
can also exhibit co-resistance to many other classes of antibiotics. This causes challenges in finding therapeutic
options.
19 the prevalence of extended-spectrum beta-lactamases (ESBLs) may be underestimated because the
Clinical and Laboratory Standards Institute (CLSI) had set resistance break-points too low.
True
False
Feedback
The answer to this question is TRUE according to the paper by Jacoby.
20 The hands of hospital personnel represents one of the major reservoirs for the persistence and potential
spread of extended-spectrum beta-lactamase (ESBL) producing strains of Klebsiella pneumoniae in the hospital
environment.
True
False
Feedback
Indeed, according to the paper by Podschum and Ullmann, the principal pathogenic reservoirs for transmission
of Klebsiella are the gastrointestinal tract and the hands of hospital personnel. Obviously, personnel who come
in contact with human excrement are most liable to spread these antibiotic resistant strains.
21 The bacterial species shown growing on 5% sheep blood agar was recovered from the spun sediment of a
midstream urine specimen after 24 hours incubation at 35C. Each of the following tests would be useful in
supporting the presumptive identification of Enterococcusspecies except: (Choose all that apply)
That's partially correct.
Pyrrolidonyl arylamidase (PYR)
Optochin Susceptibility
CAMP test
Growth in 6.5% NaCl
Feedback
The small, entire, gray, dry colonies surrounded by narrow zones of alpha hemolysis is suggestive
of Enterococcus species; however, alpha hemolytic streptococci and S. pneumoniae must also be ruled out. A
positive PYR test and the ability to grow in 6.5% NaCl are confirmatory for Enterococcus species. Susceptibility to
optochin is used primarily to differentiate S. pneumoniae (positive) from alpha streptococci and enterococci
(both negative), and the CAMP test is used to identify group B streptococci.
22 The spot test that is helpful in separating Enterococcus species (positive as shown in the image) from the
viridans streptococci and S. pneumoniae (both negative) is:
The correct answer is PYR
23 In this image is a quadrant plate containing brain heart infusion agar supplemented with 6 ug/mL of
vancomycin. The right upper quadrant was inoculated with the test strain ofEnterococcus faecium. The presen
ce of growth in the inoculated quadrant indicates resistance to vancomycin.
True
False
Feedback
The presence of growth on the vancomycin screening plate indicates that this isolate is resistant to
vancomycin, at least up to a level of 6 ug/mL, which is above the 4 ug/mL set by the Clinical and Laboratory
Standards Institute (CLSI, formerly NCCLS) as the cut-off. In certain circumstances, it may be necessary to
perform a minimum inhibitory concentration (MIC) susceptibility studies to determine the phenotype of a
resistant isolate
24 What is the most important modifiable risk factor for enteric colonization with vancomycinresistant Enterococcus faecium (VREF)?
.The correct answer is highlighted below
Age over 60 years
Prior antibiotic exposure
Active C.difficile infection

Hematologic malignancy
Feedback
The conclusion of the study by Garbutt, et al, is that prior antimicrobial exposures is the most important
modifiable independent risk factor for enteric carriage of VREF. A prior diagnosis ofC. difficle enteritis, rather
than current infection with this organism, was found to be related to enteric VREF carriage. Although age over
60 and the presence of a hematologic malignancy are risk factors for enteric carriage of VREF, these are less
contributory than prior antibiotic usage. Additionally, age over 60 is not a modifiable factor.
25 Gas gangrene may be seen in infections with all the following clostridia EXCEPT:
C. perfringens
C. novyi
C. septicum
C. difficile
Feedback
The clostridia usually associated with gas gangrene are C. novyi, C. perfringens, C. septicum, as well as C.
sordellii and C. histolyticum. Gas gangrene is the result of invasion and rapid necrosis of muscle, with resulting
toxicity and gas formation. Gram stains from potential clostridial infections constitute a STAT procedure. Look for
gram-positive bacilli resembling clostridia and an absence of inflammatory cells. Clostridium difficile is the
agent of antibiotic-associated colitis.
26 The Gram stain shown in the image was prepared from a positive anaerobic blood culture bottle after 36
hours incubation. Based on the morphology of the bacterial cells (some with spores, noted by the blue arrows),
what the most likely identification?

Clostridium perfringens
Clostridium septicum
Bacillus cereus
Bacteroides fragilis
Feedback
The bacterial cells are bacillary and gram variable. Both aerobic and anaerobic bacilli have a propensity to
easily over decolorize in the Gram stain; a mixed field of gram-positive and gram-negative cells, as shown in
the image, is often seen. The presence of spores rules outClostridium perfringens, which virtually never produces
spores in clinical infections. AlthoughBacillus cereus produces spores, it does so only under aerobic and not
under anaerobic conditions. Although gram-negative appearing bacilli (over decolorized) are observed, some
also possess spores, thus eliminating Bacteroides fragilis. By elimination, Clostridium septicum is the correct
answer.
27 It is important to establish a species identification of C. septicum in blood culture isolates because of its close
association with carcinoma of the colon.
True
False
Feedback
Although the reasons are not clear, there is a clear association of C. septicum septicemia and carcinoma of
the colon or cecum, carcinoma of the breast, and hematological malignancies. Further investigation for any of
these underlying conditions is necessary whenever C. septicum is identified in blood cultures
28 Match the species of anaerobes and frequently associated conditions.
Your answers are on the left. The correct answers are on the right and highlighted.
Clostridium perfringens Myonecrosis
Anaerobic cocci
Anaerobic cocci
Anaerobic cocci
Often resistant to both clindamycin and metronidazole
Occult carcinoma
Anaerobic cocci
Virulent and penicillin-resistant
29 Each of the following statements is true concerning Clostridium septicum infections EXCEPT:
Distant myonecrosis is the most lethal form
Infection is closely linked with cell-mediated immunity
A search for carcinoma of the colon is required in cases of septicemia
A high percentage of cases of invasive disease is associated with hematologic malignancy
Feedback
According to the paper published by Kornbluth, et al, Clostridium septicum infections are not closely linked with
immunosuppression or cell-mediated immunity. All other conditions included in this question are true for C.
septicum infections
30 A Gram stain of the serous exudate is shown in the image. The appropriate report would read:
Gram-positive cocci
Gram-positive cocci in tetrads and clusters
Gram-positive cocci suggestive of Staphylococcus species

Smear positive for bacteria
Feedback
In reporting out Gram stains, one should not go beyond what objective observation will allow. In this case,
bacterial cells are observed, which are spherical and gram-positive. Their arrangement in tetrads and clusters
might be helpful to the physician, suggesting staphylococci. However, one should stop short of naming
staphylococci in an official report, as the large gram-positive cocci in tetrads is also suggestive
of Micrococcus species, for which human infections have not been reported.
31 The bacterial cells shown in the image were observed in a smear prepared from the colony shown before.
Which of the following tests will help to affirm the identification ofStaphylococcus aureus?
Coagulase
Catalase
DNAse
Mannitol Fermentation
Feedback
Staphylococcus aureus can be presumptively identified if it produces a positive coagulase test, both slide and
tube, and hydrolyzes DNA. All Staphylococcus species are catalase positive; therefore, this test is not
discriminatory. At one time, the fermentation of mannitol was considered a definitive test for S. aureus;
however, with the naming of several other recently discovered clinically significant species, this test is no longer
discriminatory.
32 The tube coagulase test, shown in this image (upper tube positive), should be performed on all S. aureussuspicious isolates giving a negative slide coagulase reaction.

True
False
Feedback
The slide coagulase test measures for "bound" coagulase; the tube test for "free" coagulase. Most strains
produce both types; rare strains may produce only free coagulase. These uncommon strains therefore will only
be detected by performing the tube test, which should be performed on all clinically significant, slide testnegative isolates. The tube test should be read within four hours to detect an early positive reaction before lysis
occurs; but if negative, read again in 24 hours to detect weak, delayed coagulase activity.
33 Factors predisposing to infections with methicillin resistant Staphylococcus aureus (MRSA) include: (choose
all that apply)
Presence of chronic underlying disease

Prolonged hospital stay
Age over 60 and female gender
Prior antibiotic therapy
Feedback
In the study published by Hirshow, et al, prior antibiotic therapy and prolonged hospital stay were found to be
the prime conditions predisposing to infections with MRSA. Age, gender, and presence of underlying diseases
did not play an inordinate role in MRSA infections in the population of patients included in the study.
34 Decreasing the risk of staphylococcal colonization of indwelling catheters in the future may involve:
The elimination of bacterial adhesins
Development of specific inhibitors against host protein domains
Early removal of the catheter
Use of fibrinolysins to eliminate fibrin deposition
Feedback
Francois, et al, in their study, target host protein domains complementary to staphylococcal surface epitopes
as the cause for colonization. The development of specific inhibitors potentially can reduce this chance of
colonization. Although the elimination of bacterial adhesins and fibrin could theoretically decrease the risk of
infection, practical methods for accomplishing this are not forthcoming. Early removal of the catheter is not an
option in certain cases.
35 Patients with infections with MRSA have uniformly poorer outcomes than those infected with sensitive strains.
True
False
Feedback
The conclusion of the study by Hirshow, et al, is that differences in outcome for patients infected with MRSA did
not differ significantly from those infected with methicillin-sensitive strains.
36 The staphylococcal toxins causing the scalded skin syndrome (SSSS) have as their site of action in which of
the following layers of skin:
The stratum corneum

The zona granulosa
The basal layer of cells
The dermal/epidermal junction
Feedback
According to Ladharu, et al, the zona granulosa is the area along which the severe blister effect of the scalded
skin syndrome takes place. Affection of this more superficial layer allows regeneration of normal skin from the
basal layer of cells beneath, as soon as the action of toxin has ceased.
37 llustrated in the upper image are tiny pinpoint 24-hour colonies recovered from one of the splenic abscesses.
The wide zones of beta hemolysis are better seen in the close-in view of the 36 hour culture shown in the lower
image. Streptococcus anginosus ("milleri" ) can be suspected if one of the following odors is detected:

Sliced apples
Butterscotch
Bleach
Blue tortilla chips
Feedback
38 The small colony streptococci belonging to the "milleri" group (S. anginosus) can be suspected if a distinct
odor of caramel, butterscotch, or honeysuckle is detected. The odor of pared apples is produced by certain
strains of Alcaligenes faecalis (odoratum). The odor of bleach is characteristic of Eikenella corrodens, and the
odor of grapes or of blue tortilla chips is produced by Pseudomonas aeruginosa.
ost strains of S. anginosus (milleri) carry the F antigen (see image). Rare strains that carry the group A antigen
can be differentiated from S. pyogenes by which of the following laboratory tests:

PYR
CAMP
Esculin hydrolysis
Catalase
Feedback
Among the beta hemolytic streptococci, the rapid PYR test has proven valuable in selecting out group
A, Streptococcus pyogenes. All strains of the S. milleri complex are negative. The CAMP test is helpful in
identifying group B streptococci. Esculin hydrolysis is positive for S. anginosus ("milleri") and variable for S.
pyogenes, thus is not discriminatory (also is not a rapid test). None of the streptococci possess catalase activity;
thus, this test also is not discriminatory.
39 Most infections caused by S. anginosus can be effectively treated with penicillin or a first generation
cephalosporin.
True
False
Feedback
Indeed, according to the paper published by Pistelli, et al, most strains of S. anginosus (milleri)are susceptible to
penicillin G and the cephalosporins
The epidural and subdural abscesses in the two patients reported by Gelfand, et al, are clinical manifestations
uncommon for S. anginosus ("milleri").
True
False
Feedback
Infections with purulent abscess formation are commonly caused by S. anginosus ("milleri"), including intra
pelvic, intra abdominal, subcutaneous and central nervous system among other sites. Infections in the epidural
and subdural regions are rare.
40 A clinical condition often associated with Streptococcus anginosus ("milleri") is:
Endocarditis
Intra abdominal abscess
Carcinoma of the colon
Cellulitis
Feedback
Of the possibilities listed, S. anginosus ("milleri") is most commonly associated with intra-abdominal and deep
organ abscesses. Indeed, according to the paper by Piscitelli, et al, "these organisms are often associated with
various pyogenic infections including cardiac, intra-abdominal, subcutaneous and central nervous system
infections, particularly with the formation of abscesses." Although cardiac abscess have been reported;
endocarditis is rare. Carcinoma of the colon is more commonly associated with group D Streptococcus bovis,
and cellulitis is more commonly associated with Streptococcus pyogenes.
41 The image shows the Gram stain prepared from the positive blood culture. What is the appropriate report?

Gram-positive cocci
Gram-positive cocci in chains
Gram-positive cocci consistent with Streptococcus
Gram-positive cocci consistent with Enterococcus
Feedback
Although any one of the answers might be considered correct, a report of gram-positive cocci in chains
provides sufficient information without going beyond what the observation might allow. In off-the record
conversation with the physician, a technologist might divulge that the picture is consistent with Streptococcus;
however, enterococci may have a similar Gram stain appearance, potentially leading to the wrong choice of
empiric antibiotic agents.
Beta hemolytic colonies grew from the blood culture bottle after 18 hours incubation (see image). Which of
following tests would be helpful in making a preliminary identification? (Choose all that apply)
PYR
Catalase
Bacitracin susceptibility
SXT susceptibility
Feedback
The beta hemolytic streptococci most commonly recovered from clinical specimens fall in to the Lancefield
groups A, B, C, and G. Of the answers listed, all would be helpful in making a presumptive identification.
Streptococci are catalase negative while the Staphylococci are catalase positive - helpful in establishing a
genus identification. Group A streptococci are PYR Positive, susceptible to low concentrations of bacitracin ("A"
disk) and, along with Group B streptococci, are resistant to SXT. The specific group antigen can be
demonstrated by follow-up serological tests.
42 Thus, in follow-up to the previous discussion, the reaction shown in the image establishes the identification of
a group A, beta hemolytic streptococcus.

True
False
Feedback
The intended response is "true". The Centers for Disease Control (CDC) have decreed that any zone of inhibition
around the 0.04 ug bacitracin disk ("A" disk) allows a presumptive identification of Streptococcus pyogenes,
group A. You cannot be called totally wrong if you answered "false". Streptococci other than Group A may
produce a "narrow zone" of hemolysis (14 mm or less). In such instances, a second test or serologic testing
should be performed to confirm the identification.
43 What is a major complication of toxic shock syndrome related to group A streptococci, leading to 50%
mortality?
Septicemia
Necrotizing ("flesh-eating") cellulitis
Rapidly progressing organ failure
Multi-focal osteomyelitis
Feedback
Although each of the complications listed in this question are serious manifestations of toxic shock syndrome,
the conclusion in Spencer's paper is that rapidly progressing organ failure is responsible for most fatal outcomes.
44 What are the factors related to the strong resistance of certain strains of group A streptococci to
phagocytosis? (Choose all that apply)
Complementary immunoglobulin-binding proteins
Nephritic strain-associated protein
Fibrinogen binding by M protein
C5a peptidase activity
Feedback
The conclusion of the study by Cunningham targets the binding of fibrinogen by M protein and the disarming of
complement component C5a by C5a peptdiase activity as two major factors in the antiphagocytic activity of
group A streptococci. Complementary immunoglobulin-binding proteins are involved in rheumatic fever and
the nephritic strain-associated proteins are related to glomerulonephritis.
45 A Brown and Brenn gram stain was performed on one of the tissue biopsy specimens. Organisms were seen
as shown in the image. Based on the history and the appearance of the bacteria, the most likely identification
is:
Listeria monocytogenes
Haemophilus influenzae
Feedback
The organisms shown appear as short to slightly elongated gram-positive bacilli with rounded ends. The most
probable identification is Listeria monocytogenes, although Clostridium septicum cannot be ruled out. The
latter usually produces spores and the history is not consistent. Culture is necessary for
confirmation. Streptococcus agalactiae could cause the clinical symptoms, but the bacterial cells are grampositive cocci in chains. H. influenzaeproduces thin, pleomorphic, gram-negative bacilli.
46 Shown in the image is a close-in view of the colony growth after 48 hours incubation. What are the possible
presumptive identifications suggested by the colonies observed? (Choose all that apply)

Staphylococcus aureus
Listeria monocytogenes
Streptococcus pyogenes
Feedback
Small, gray, translucent, beta hemolytic colonies recovered from a spinal fluid culture would suggest either a
streptococcus, most likely S. agalactiae (group B), or Listeria monocytogenes. Group A, Streptococcus
pyogenes should also be considered, although the intensity of the hemolysis is usually much greater than seen
here. The colonies of S. aureusare much larger, opaque; and hemolysis, when present, is more pronounced.
47 What test(s) which may be performed to establish a presumptive differential identification between group B
streptococci and L. monocytogenes?
Gram stain
Catalase
Motility
All of the above
Feedback
A Gram stain, spot catalase test, and a direct mount observing for motility may aid in separating these two
species. L. monocytogenes will give a positive spot catalase test, and the bacterial cells will show "tumbling
motility" when microscopically observed in a direct mount, thereby eliminating the catalase-negative, nonmotile streptococci.
48 Shown in theimage are three tubes: (1) motility agar (note subsurface flare shown by arrows); (2) esculin
hydrolysis (+), and (3) VP (+). The reactions illustrated here are sufficient to rule outErysipelothrix rhusiopathiae.
True
False
Feedback
Erysipelothrix rhusiopathiae may have colony and Gram stain features similar to that ofListeria monocytogenes.
However, L. monocytogenes is motile (optimum at room temperature or 25C), hydrolyzes esculin (black), and
gives a positive VP reaction (red). E. rhusiopathiae is negative for all these tests. E. rhusiopathiae produces H2S
in Kligler and Triple Sugar Iron Agar while L. monocytogenes does not.
49 Which of the following is NOT related to the virulence of Listeria monocytogenes?

Intracellular phagosome escape
Production of a potent exotoxin
Suppurative hepatitis and organism release
Open intestinal portal of entry through Pyers patches
Feedback
In the paper by Rouquette and Berche, the following sequence of events leads to disseminated listeriosis:
intestinal entry of organisms through Pyers patches, invasion of mesentric lymph nodes, invasion of host cells
and escape from the phagosomes, transport to the liver and invasion of hepatocytes, replication and release
into the blood stream following cytolysis by the action of polymorphonuclear leukocytes, prolonged
septicemia, and CNS invasion.
50 Which of the following factors has NOT led to the current increase in incidence of listeriosis?
Increase in average human life span
Long survival of patients with immunodeficiency diseases
Plasmid-related mutations of the organism
Ability of the organism to grow at low temperatures
Feedback
Rocourt, et al, in their paper, list all of the answers to this question as factors related to the increased incidence
of listeriosis except organism mutation. Although plasmid-mediated alterations in expression of virulence can
certainly occur, this was not mentioned in this paper as a major factor related to the current increase in
incidence of listeriosis.
51 A characteristic of the virulence of L. monocytogenes is its unique ability to invade peripheral nerves and
rapidly enter into the brain.
True
False
Feedback
Indeed, Low and Donache, in their paper, cite peripheral nerve invasion as a unique virulence factor
characteristic of L. monocytogenes.
52 A bacterial isolate that produces pitting of the agar and has a bleach-like odor is probablyE. corrodens.
What are the closely related species that must be ruled out? (Choose all that apply)
Haemophilus aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Kingella kingae
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Eikenella corrodens belongs to a loosely defined group of fastidious gram-negative bacilli known as the HACEK
group. The positive oxidase reaction would help to rule outHaemophilus aphrophilus, previously mentioned,
and Actinobacillus actinomycetemcomitans, both of which are negative. Of the HACEK
group,Cardiobacerium hominis and Kingella species are also catalase negative and oxidase positive. Neither,
however produce a bleach-like odor.
53 Which of the following result in most Eikenella cellulitis infections?
Human bites
Pet animal bites
Penetrating injury
Direct skin to skin contact
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The human oropharynx is the normal habitat for E. corrodens and most infections are caused by entry of human
saliva into a wound. A human bite provides both the means of skin penetration and the exposure to
contaminated saliva. The "clenched fist syndrome" (infection of the knuckles after punching a fellow human in
the teeth) and "skin popping" (licking the needle before injection of an illicit drug) are other means for
acquiring infection.Pasteurella multocida and Capnocytophaga canimorsus are associated with dog and cat
bites. E. corrodens does not survive on objects causing penetrating injury and skin to skin transmission is an
unlikely event (excluding wrestlers, perhaps!).
54 In view of the feedback to the previous question, what is the most likely reason that the clinical correlation
does not seem to fit in this case?
The history is wrong or incomplete
The organism identification is incorrect
A second unrecovered organism was involved
Any of the above
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Indeed, any of the answers can be incriminated. In the real-life situation of the case presented, when initially
asked, the patient denied a human bite. When asked about a possible "skin popping" episode, he became a
bit defensive. Later he remembered a scuffle he had in a bar the previous Saturday night. "That SOB must have
bit me" was his next reply! One nonetheless must always consider that a second organism (particularly an
anaerobe) may be involved in cases where there is a disconnect between the species identification and the
clinical story.
55 Human bite wound infections are categorically more severe and more often lead to complications than
infected bites from other animals.
True
False
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Griego, et al, in their paper, conclude that, with the exception of hand wounds, infections from human bites
are of no greater consequence than the infections caused by bites from other animals.
56 To avoid infection with E. corrodens, what are patients with insulin-dependent diabetes mellitis (IDDM)
advised NOT to do? (Choose all that apply)
Chew their fingernails
Be bitten or scratched by house pets
Lick needles used for insulin injections
Engage in bare knuckle fights
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Human Eikenella corrodens infections are not commonly related to animal bites. Patients with IDDM should be
counseled to avoid any activity that brings human saliva in contact with subcutaneous tissue. Newfield, et al,
present cases histories of Eikenella infections in patients with IDDM, one related to finger and fingernail
chewing, and the second who developed an abscess at the insulin-injection site related to prior licking of the
needle. Numerous case reports of "clenched fist" syndrome have been reported in the recent literature.
57 sWe can conclude from Robinson & Kourtis' "Tale of the Toothpick", that, "it is unwise to place a used
toothpick in your pocket."
True
False
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Perhaps a stretch of the imagination, but the case of toothpick osteomyelitis reported by Robinson and Kourtis
puts us on alert to take care in discarding used toothpicks (heavily contaminated with E. corrodens). A
pocketed toothpick may either cause a puncture wound of the fingers or hand when reaching in to the
pocket; or, of the thigh by direct penetration. Perhaps we can also add the adage, "don't substitute a
toothpick for a sword"!

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49 Which of the following is NOT related to the virulence of Listeria monocytogenes?

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