Lesson N12 LABORATORY DIAGNOSIS OF ZOONOSIS (PLAGUE, TULARAEMIA, BRUCELLOSIS AND ANTHRAX)

1.Scientifically methodical ground of theme Thise group of diverse organisms is presented togerther as the mode of transmission is zoonotic. The resorvoir of infection is animals. Tramsmission may occur directly by contact or bites of animals or through an insect vector where the insect feeds on an animal and transmit the organisms to human.2.Educational purpose

STUDENTS MUST KNOW:

1. Structure, tinctorial properties and cultivation of Y. pestis, F. tularensis, B. anthracis and causative agents of brucellosis

2. Antigenic structure of these microorganisms3. Fermentative properties and toxin production of causative agents of zoonosis4. Epidemiology and pathogenesis of plague, tularemia, brucellosis, anthrax.5. Methods of laboratory diagnosis of diseases, main methods of prophylaxis and

treatment.

STUDENTS SHOULD BE ABLE TO:

– make microscopical examination of the smears;– value the growth of bacteria on different nutrient media; – read the result of Wright’s test for serological diagnosis of brucellosis;

– carry out an Huddleson’s agglutination test for accelerated diagnostics brucellosis.

– make up conclusion about Huddleson’s and Wright’s tests– create scheme of diagnosis of plague, tularemia, brucellosis and anthrax

– choose biological preparation, which are used for laboratory diagnosis and specific prophylaxis of plague ,tularemia, brucellosis and anthrax

3.Chart of topic content.Fig.N1:Yersinia Virulence Factors in Human Disease

Factor Apparent FunctionFraction 1 capsule AntiphagocyticV/W antigens Suppress granuloma formationFibrinolysin Tissue invasionLow Ca2+ response gene

YOP synthesis

YOP H Protein tyrosine phosphataseYOP K & L Inhibit cell-mediated immune

response

Laboratory diagnosis. Examination is carried out in special laboratories and in antiplague protective clothing. A strict work regimen must be observed. Depending on the clinical form of the disease and the location of the causative agent, test specimens are collected from bubo content (in bubonic plague), ulcer secretions (in cutaneous plague), mucus from the pharynx and sputum (in pneumonic plague), and blood (in septicaemic plague). Test matter is also recovered from necropsy material (organs, blood, lungs, contents of lymph nodes), rodent cadavers, fleas, foodstuff's, water, air, etc. Examination is performed in the following stages.

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1. Microscopy of smears, fixed in Nikiforov's mixture and stained by the Gram method or with methylene blue by Loeffler's method.

2. Inoculation of the test material into nutrient media, isolation of a pure culture and its identification. To inhibit the growth of the accompanying microflora, 1 ml of a 2.5 per cent sodium sulphite solution and 1 ml of a concentrated alcohol solution of gentian violet, diluted in distilled water in a ratio of 1 :100, are added to 100 ml of meat-peptone agar. Prior to inoculation 0.1 ml of antiphage serum is added to the culture to render the plague bacteriophage harmless.

3. Biological tests of the isolated pure culture and of material from which isolation of the organism is difficult are conducted on guinea pigs. In the latter case a thick emulsion prepared from the test material is rubbed into a shaven area of skin on the abdomen. If plague bacilli are present the animals die on the fifth-seventh day. To hasten diagnosis the infected guinea pigs are killed on the second-third day and the plague bacillus is isolated from their organs.

Y. pestis is identified by determining the morphological, cultural, fermentative, phagocytolytic, and agglutinative properties of the isolated culture. The growth is differentiated from the causative agent of rodent pseudotuberculosis (see Table 1). The biological test is decisive in the diagnosis of plague.

Decomposed rodent cadavers are examined by the thermoprecipitin test.The importance of prompt diagnosis of plague has led 10 the elaboration of accelerated diagnostic methods in recent times

Laboratory diagnosis. The differential diagnosis of plague, anthrax, enteric fever, typhus fever, influenza, malaria, and brucellosis is difficult because these diseases have common symptoms. For differentiation of tularaemia from other diseases laboratory tests are the most effective. Those peculiarities of the disease which can be revealed easily and quickly by laboratory methods are taken into account.

1. Allergy develops on the third-fifth day of the disease. For this reason, intracutaneous and cutaneous tests with tularine are made for early diagnosis. In tularaemia patients the test gives a positive reaction 6-12 hours after inoculation of tularine. In distinguishing tularaemia from other infections one must bear in mind that allergic tests may show positive reactions in convalescents and vaccinated individuals.

2. In the second week of the disease agglutinins begin to accumulate in the blood. They are detected by carrying out the agglutination reaction by the blood-drop and volume methods. In some cases this test may give a positive reaction with material containing brucella organisms, since they possess antigens common to tularaemia bacteria.

3. The tularaemia culture is isolated by the biological method as it is impossible to recover the pathogen directly from a tularaemia patient. For this purpose white mice or guinea pigs are infected by material obtained from people suffering from the disease (bubo punctate, scrapings from ulcers, conjunctiva! discharge, throat films, sputum, and blood). Biological tests are conducted in special laboratories where a standard regimen is observed. The laboratory animals die in 4-12 days if tularaemia bacteria are present in the test material. Autopsy is performed, smears from organs are made and organ specimens are inoculated onto coagulated egg medium for culture isolation. Microscopic, microbiological, and biological studies of the cultured organisms are made. If no culture can be isolated from the first infected guinea pig, an emulsion, obtained from the latter's organs, is inoculated into a second guinea pig, etc.

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4. Laboratory diagnosis of rodent tularaemia is made by microscopy of smears from organs, precipitin ring reaction (thermoprecipitation), and biological tests.

Water, foodstuffs, and blood-sucking arthropods are examined by biological tests.

Species

Bio

type

Req

uire

men

ts f

or C

O2

H2S

pro

duct

ion

Growth on media with

dyes

Agl

utin

atio

n in

m

onos

peci

fic

sera

AM

Lys

is u

nder

eff

ect o

f T

-b

phag

e in

TD

Metabolic tests

thionin

basic fuchsi

n

glut

ami-

nic

acid

argi

nine

ribo

se

lysi

ne

abc bc

B. melitensis

1 – – – + + + + – + – + – – –

2 – – – + + + + + – – + – – –3 – – – + + + + + + – + – – –

B. abortus

1 +(–) + – – – + + + – + + – + –

2 +(–) + – – – – – + – + + – + –3 +(–) + + + + + + + – + + – + –4 +(–) + – – – + + – + + + – + –5 – – – + + + + + – + + – + –6 – – + – + + + + + – + + – + –7 – + – – + + + – + + + + + – + –8 + – – + + + + – + + + – + –9 – + – + + + + – + + + – + +

B. suis 1 – + + + + – – + – – – + + –2 – – – + + – – + – – + + + +3 – – + + + + + + – – + + + +4 – – + + + + + + + – + + +

B. neotomae

1 – + – – + – – + – – + – ± –

B. ovis + – + + + – – – + – – –B. canis – – – + + – – – – + + +

Laboratory diagnosis. The patient's blood and urine (for isolation of the pathogen), serum (for detection of agglutinins), milk and dairy products (for detection of brucellae or agglutinins in milk) are examined. The microbe is isolated in special laboratories.

1. Culture isolation. Since brucellosis is often accompanied by bacteraemia, blood is examined during the first days of the disease (preferably when the patient has a high temperature). For this purpose, 5-10 ml of blood is collected and transferred into two or three flasks (2-5 ml per flask) containing 100 ml of liver-extract or ascitic-fluid broth (pH 6.8). The cultures are grown for 3-4 weeks or more. Five to ten per cent of carbon dioxide is introduced into one of the flasks (for growth of the 23 bovine species of the bacteria). Inoculations on agar slants are made every 4-5 days for isolation and identification 'of the pure culture.

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An antiphage serum is introduced into the cultures for neutralization of the phage which inhibits the growth of brucellae. The best results are obtained when the blood is inoculated into the yolk of an unfertilized egg or the yolk sac of a chick embryo. For this, 0.1-0.2 ml of the tested blood diluted in citrate broth in a ratio of 1 : 3 is introduced into each egg. The infected eggs are placed in an incubation chamber for 5 days, after which 0.3-0.5 ml of their contents is inoculated into the liquid nutrient media. Growth is examined every 2-3 days.

If the blood culture produces a negative result bone marrow obtained by sternum puncture is inoculated onto solid and liquid media for isolation of myelocultures.

The urine is also examined. It is obtained with a catheter, centrifuged, and 0.1 ml of the precipitate is seeded onto agar plates containing 1 :200000 gentian violet. In some cases faeces, cow's and human milk, and amniotic fluid of sick humans and animals are examined for the presence of Brucella organisms.

Brucella cultures may be isolated by the biological method. For this purpose healthy guinea pigs or white mice are injected with 0.5 or 3 ml of the test material. A month later the guinea pigs' blood is tested for agglutinins, the allergic test is carried out, and the pure culture is isolated. White mice are tested bacteriologically every three weeks.

2. Serological test. From the tenth-twelfth day of the disease onwards, the agglutinins accumulate in the blood in an amount sufficient for their detection by the agglutination tests. The Wright (in test tubes) and Huddleson (on glass) reactions are carried out. The Wright reaction is valued highly positive in a 1 800 serum dilution, positive in a 1 :400-1 :200 dilution, weakly positive in 1 :100 dilution, and doubtful at a titre of 1 :50.

The Huddleson reaction is used mainly in mass examinations for brucellosis.However, there is a disadvantage of this reaction in that it sometimes shows positive

results with sera of healthy individuals who have normal antibodies in their blood.3. Skin allergic test. To determine allergy, Burne's test is made beginning from the

fifteenth-twentieth day of the disease. A 0.1 ml sample of the filtrate of a 3- or 4-week-old broth culture (brucellin) is injected intracutaneously into the forearm. The test is considered positive if a painful red swelling 4 by 6 cm in size appears within 24 hours (Plate III).

4. Opsono-phagocytic test. This test detects changes in the phagocytic reaction. The index of healthy individuals averages 0-1 and occasionally 3-5. In sick persons the reaction is considered high if the index is 50-70, mild, if it is 25-49, and low, if it is 10-24.

For detecting brucellae in the external environment the reaction for demonstrating a rise in bacteriophage titre is carried out. 5. In some cases the complement-fixation test, the indirect haemagglutination reaction, and the immunofluorescence reaction are used.

Components of Anthrax ToxinCompone

ntFunction

EE Inactive adenylate cyclase activated by calmodulin

LF Causes pulmonary edema and death in rats; cytolytic for macrophages

PA Required for the binding of both EF and LF to host cell

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EF, edema factor, LF, lethal factor, PA, protective antigen

Laboratory diagnosis. In cases of cutaneous anthrax the malignant pustular exudate is examined; it is obtained from the deep layers of the oedematous area where it borders with the healthy tissues. Sputum is examined in cases of the respiratory form, faeces and urine, in intestinal form, and blood is examined in cases of septicaemia.

1. The specimens are examined under the microscope, the smears are Gram-stained, or stained by the Romanowsky-Giemsa method. The presence of morphologically characteristic capsulated bacilli, arranged in chains, allows a preliminary diagnosis.

2. For isolation of the pure culture the specimens are inoculated into meat-peptone agar and meat-peptone broth. The isolated culture is differentiated from other morphologically similar bacteria by its morphological and biochemical properties.

3. Laboratory animals (white mice, guinea pigs and rabbits) are inoculated with the pathological material and with the pure culture de-rived from it. B. anthracis causes the death of white mice in 24-48 hours and of guinea pigs in 2-3 days following inoculation. Microscopic examination of smears made from blood and internal organs reveals anthrax bacilli which are surrounded by a capsule.

A rapid biological test is also employed. The culture obtained which has to be identified is introduced intraperitoneally into white mice. Several hours after inoculation smears are prepared from the peritoneal contents. Detection of typical capsulated bacilli gives a basis for con-firming the final result of the biological test.

The allergic test with anthracin (a purified anthrax allergen) is employed when a retrospective diagnosis is required in cases which have yielded negative results with microscopical and bacteriological examination.

Postmortem material as well as leather and fur used as raw materials are examined serologically by the thermoprecipitin reaction (Ascoli's test) since isolation of the bacilli is a matter of difficulty in such cases.

The result in the first test tube (containing the test material) may be either positive or negative, in the second test tube (control) it must be only positive, and in the third, fourth, fifth, and sixth control test tubes the results must always be negative.

When employing laboratory diagnosis of anthrax, one must bear in mind the possibility of the presence of bacteria identical with B. anthracis in their biological properties (see Table 1). These sporing aerobes are widely distributed in nature and are normally sporeforming saprophytes. They include B. cereus, B. subtilis, B. megaterium, etc.

The anthrax bacilli may be differentiated from anthracoids (false anthrax organisms) and other similar sporing aerobes by phagodiagnosis. The specific bacteriophage only causes lysis of the B. anthracis culture.

4. Student’s independent study program1. Structure, staining properties of causative agent of plague, tularemia, brucellosis

and anthrax . Cultivation.2. Biochemical and other differential diagnistic properties of causative agent of

plague, tularemia, brucellosis and anthrax3. Antigenic structure and toxon production and virulence factors.4. Reservoir of these diseases in nature, source of infectious agents, mechanisms of

transmission, vectors.

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5. Main clinical forms of diseases(plague, tularemia, brucellosis and anthrax ).6. Laboratory diagnosis of plague, tularemia, brucellosis and anthraxa – collection of tested material b – main methods of diagnosisc-bacterioscopyd - stages of bacteriological diagnosis; e – serological methodh – feature of biological method of diagnosis;g-allergic method7. Methods of zoonosis prophylaxis .

5. Students’ practical activities:1 . To examine under the microscope the smears of causative agent s of zoonosis in

museum preparations. Drow your observation .Y.pestis stains with ordinary aniline dyes and given bipolar appearance, its ends

staining more intensively. It is Gram negative. Y.pestis is characterized by marked individual variability (pleomorphism). In smears from organs and in young cultures it has an ovoid shape, while in cultures on solid media it is elongated and sometimes thread-like.

The tularaemia bacteria (F. tularensis) are short coccal-shaped or rod-like cocci measuring 0.2-0.7 mcm. In old 'cultures the organisms retain the coccal form. They are non-motile, and Gram-negative. In the animal body they are sometimes surrounded by a fine capsule.

Brucellae are small, coccal, ovoid-shaped micro-organisms 0.5-0.7 mcm in size. Elongated forms are b.6-1.5 mem in length and 0.4 mcm in breadth. Under the electron microscope Brucella organisms of cattle, sheep and goats appear as coccal and coccobacilary forms, while those of pigs are rod-shaped. They are Gram-negative, non-motile, and do not form spores or capsules (in some strains capsules are sometimes present).

B. anthracis is among the largest of all bacterial pathogen, composed of block-shaped, angular nonmotile rod 3-5 mkm long and 1-1,2mkm wide. Division begins before the cells have separated after the previous division, which leads to the formation of streptobacilli. Outside the host's body they produce oval-shaped central spores which are smaller in diameter than the bacillus. In the bodies of man and animals the bacilli produce capsules which surround a single organism or are continuous over the whole chain.

2.Read the result of Wright’s test with patient’s serum for serological diagnosis of brucellosis. Make up conclusion and record your observation.

To carry out a standard agglutination test, on the second week of the disease (the 10th–15th day) withdraw 2-3 ml of blood from the patient's cubital vein. Dilute successively the obtained serum (Table 2) with isotonic saline in titres from 1:25 to 1:400.

Schematic Representation of the Agglutination Reaction

Ingredient

Number of the test tube1 2 3 4 5 6

antigen control

7 serum control

Isotonic sodium chloride solution,

1 1 1 1 1 1 –

6

mlThe diagnostic serum in a 1:50 dilution, ml

1 1 1 11

– 1

The obtained dilution of the serum

1:100 1:200 1:400 1:800 1:1600 – 1:50

Bacterial suspension, drops

2 2 2 2 2 2 –

Incubation at 37 0C for 2 hrs, then at room temperature for 18-20 hrs

Wright’s reaction is performed at the beginning of the second week of the disease. Suspension of killed Brucella organisms stained with gentian violet or methylene violet and containing 1 mird of brucellae (per ml) killed with formalin or phenol is used as a diagnosticum. Currently a uniform colour brucellar diagnosticum for Wright's and Huddleson's tests is commercially available.

The procedure of performing the Wright test is similar to that used in other agglutination tests, with the exception of the fact that the serum is diluted in a multiple order with isotonic NaCI solution containing 0.5 per cent of phenol. The test tubes are placed in the incubator for 18–20 hrs and then left at room temperature for 2 hrs. The results of agglutination are denoted with pluses. The reaction is considered positive if the titre is 1:200 and doubtful if it is 1:50. Wright's reaction may be positive in vaccinated subjects and patients with brucellosis. So, it is to be repeated in the course of the disease to look for increase in the antibody litre.

6. To carry out Huddleson’s agglutination test for serological diagnosis of brucellosis. Read the result of test. Make up conclusion and record your observation.

The plate agglutination test proposed by Huddleson (Table 3) is most frequently used in brucellosis foci (in field conditions) since it is simple to perform. Using a wax pencil, divide a glass plate into six squares, then pipette on them undiluted serum to be studied in 0.08, 0.04, 0.02, 0.01, and 0.02-ml portions, and add 0.03 ml of the same diagnosticum that is used in Wright's reaction to each dose of the serum but the last (the fifth square) into which 0.03 ml of isotonic sodium chloride solution (control of the serum) is placed. In the sixth square, place 0.03 ml of the antigen and 0.03 ml of isotonic saline (control of the diagnosticum). Mix drops of the serum and antigen with a glass rod and after slight rocking of the plate read the results of the reaction which is manifested already in the first minutes by the appearance of microgranular stained agglutinate. The absence of agglutination in all doses of the serum is assessed as a negative reaction, the presence of agglutination in the first dose (0.08 ml of the serum) as a doubtful one, in the second dose (0.04 ml), as a weakly positive one, in the third or fourth doses (0.02–0.01 ml), as a positive one; the agglutination reaction expressed by 4 pluses in all doses is evaluated as a drastically positive one. The value of Huddleson's agglutination test is diminished by the fact that not infrequently it produces positive results with healthy people's sera due to the presence of normal antibodies. Hence, sera showing positive Huddleson's reaction should be subjected to the tube agglutination test.

Table 3

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Schematic Representation of Huddleson's Agglutination Test

Ingredient, mlNumber of square Control

1 2 3 4

of serum

of antigen

5 6

Isotonic saline – – – – 0.03 0.03Patient's serum 0.08 0.04 0.02 0.01 0.02 –Diagnosticum 0.03 0.03 0.03 0.03 – 0.03

6. To familiarize with biological preparation, which are used for laboratory diagnosis and specific prophylaxis of plague , tularemia , brucellosis and anthrax 6. Control questions and tests:

Select the correct answers. 1. Causative agent of a plague has such properties: a – gram-positive; b – forms long chains in smears; c – ovoid-sharped form with tendency to bipolar staining; d – delicate capsule; e – forms spores.2. Cultivation of Y. pestis: a – microbes are undemanding (unpretentious) to nutrient media; b – bacteria form

colonies with turbid white centres, and scalloped boders resembling lace or crumpled lace handkerchief; c – grow slowly; d – anaerobe; e – on blood agar forms hemolysis.

3. Toxic properties of causative agents of a plague: a – form endotoxin; b – form lethal, mouse toxin; c – have coagulase; d – form protein toxin; e – produce hyaluronidase.4. Antigenic structure of Y. pestis: a – has themostable lipopolysaccharide O–antigen; b – has V–antigen – protein; c –

has H-antigen; d – has W-antigen – lipoprotein; e – has Vi–antigen.5. Resistance of Y. pestis: a – boiling kills microbes within 1 min; b – temperature 22 С kills bacteria; c – in 3 % phenol solution survive 10 min; d – alcohol kills bacteria in 3 – 5 min.6. Mechanism of plague transmission: a – airborne; b – by the bites of flea; c – fecal–oral; d – direct contact; e – by the foodstuff.7. Tested materials for plague diagnosis are: a – blood; b – sputum; c – pus; d – puncture samples from a bubo; e – smear from

stomatopharynx 8. For laboratory diagnosis of a plague use: a – bacteriological method; b – biological method; c – serological method; d – allergic method; e – immunofluorescent test. 9.F. tularensis has such properties: 1.A – diplobacteria; b – coccobacteria; c – Gram-positive; d – produces spores; e –

produces capsulae.10. A – grows on simple media; b – grows on MacCou’s and Chepin’s media; c –

obligate aerobes; d – the isolated colonies don’t appear on the media after inoculation of material tested which was taken from the man; e – grows onto media with a blood and cystine.

11. A - has an O-antigen; b – has a Vi-antigen; c – forms an endotoxin; d – produces protein toxin; e – has a K-antigen.

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12 A – resistant to low temperatures; b – resistant to high temperatures; c – sensitive to disinfectant solutions; d – resistant to alcohol; e – stands boiling for 30 minutes.

13. Epidemiology of a tularemia: a – the source of infection is rodents; b – the source of infection is sick persons; c – disease is transmitted by the bites of arthropods and insects; d – the causative agent penetrates through an uninjured skin. 14. For diagnostics of tularemia are used: a – bacteriological method; b – blood-drop agglutination test; c – ELISA; d – CFT; e – allergic test.

15. For prophylaxis of tularemia are used: a – attenuated Gayskiy-Elbert’s vaccine; b – tularin; c – inactivated vaccine; d – anatoxin; e – immunoglobulin.

16. Brucella have such properties: a – gram-negative; b – small coccobacteria; c – motile; d – produce spores; e – produce capsula.

17. One can differentiate Brucella using: a – grows at presence of 5– 10 % of carbon dioxyde; b – B. suis produces hydrogen sulphide; c – B. melitensis grows on media with thionine (1: 25000); d – B. abortus is sensitively to specific phage; e – B. suis ferments xylose.

18. The causative agents of brucellosis may be transmitted by: a – air–born mechanism; b – alimentary mechanism (through the milk, foodstuff; c – the bites of arthropods and insects; d – from the bacterial carrier by a contact mechanism; e – contact mechanism from the sick animals.

19. For bacteriological diagnosis of brucellosis are used: a – blood; b – punctate of a marrow; c – urine; d – faeces; e – milk.

20. For diagnosis such methods are used: a – bacterioscopic method; b – bacteriological method; c – Huddleson’s agglutination test; d – IHA test; e – allergy test.

21. Prophylaxis and treatment of brucellosis: a – live attenuated vaccine; b – inactivated vaccine; c – anatoxin; d – live selective vaccine; e – immunoglobulin22. B. anthracis has such properties: A – gram-positive; b – produces spore; c – produce capsule outside organism; d –

peritrichous, motile; e – streptobacillus, resembling bamboo canes with elbow-shaped articulation.

23. Cultivation of B. anthracis:A – in MPB B. anthracis produces flocculent growth resembling cotton wool which

sinks to the bottom of the tube; b – on MPA B. anthracis produces colonies resembling crumpled lace handkerchiefs; c – on MPA colonies have uneven edges and resemble the head of medusa; d – in gelatin stab-cultures growth resembles an inverted fir tree; e – on blood agar B. anthracis causes hemolysis.

24. B. anthracis produces:A –oedema factor and protective antigen; b – endotoxins; c – lethal toxin; d – lecithinase; e – enterotoxin.25. Antigenic structure of B. anthracis and tests for determination of antigen:А – O–antigen, agglutination test; b – O–antigen, thermoprecipitation test; c – K–antigen, phagocytosis; d – protective antigen, precipitation test, e – Н–antigen, agglutination test.26. Disinfection of pathologic material is spent by:А – autoclaving at 110 С 40 min; b – boiling at 100 С 1 min; c – autoclaving at

120 С 90 min; d – boiling in 1 % solution of soda for 2 hrs; e – burning or immersion in concentrated sulfuric acid.

27. What tested material are examined in various clinical forms of anthrax:

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А – urine (septic form); b – feces (intestinal form); c – punctate of lymph nodes (cutaneous form); d – pus (cutaneous form); e – sputum (respiratory form).

28. Methods of laboratory diagnosis of anthrax:А – biological; b – ELISA; c – thermoprecipitation test; d – allergy test; e –

bacteriological method.29. Bacterial preparation which use for active and passive prophylaxis:А – antianthrax immunoglobulin; b – anthrax toxin; c – live anthrax vaccine; d – inactivated anthrax vaccine; e – anthrax antitoxin.

30. Each of following statements concerning plague is correct EXCEPT:A. Plague is caused by gram-negative rods which can be caltivated on blood

agarB. Plague is transmitted to humans by flea biteC. The main resorvoir in nature are small rodentsD. Plague occurs only in underdeveloped countries

31. Which one of following statements concerning the organisms that cause brucellosis is CORRECT?

A. Brucellae are transmitted primery by tick biteB. The principal resorvoir in nature are small rodentsC. Brucellae are found in reticuloendothelial cells and often cause

graanulomatous lesionsD. Brucellae are obligate intracellular parasites that are usually identified by grow in human cell culture

32. A patient with brucellosis is found to have a positive skin test (brucelin test). Which of the following factors can induce such reaction?

A. IgА.B. T-cellsC. IgE. D. IgG.E. IgD.33. The territory of old tomb cattle yard, which was not used for more than 50 years,

is planned for house building. However, soil investigation has shown the presence of viable spores of the causative agent of especially dangerous disease. Name microorganisms, which could be kept in soil during such a long time?

A. Yersinia pestis.B. Francisella tularensis.C. Brucella abortus.D. Bacillus anthracis.E. Mycobacterium bovis.34. A 34 year-old- patient complained of carbuncle on his face. His examination

revealed subcutaneous painful edema with black eschar in the center, vesicular eruption on circumference. Microbiologic examination revealed nonmotile, capsule-, forming streptobacillli. What microorganisms are causative agents of this disease?

A. Bacillus anthracis.B. Staphylococcus aureus.C. Bacillus anthracoides.D. Bacillus subtilis.E. Bacillus megaterium.

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35. In laboratory for examination of animal skin the precipitation test is used (Askoly test). Result: in some minutes after adding immune serum to skinr extract albescent ring has been formed. What does this result say about?

A. Presence of Bacillus anthracis antigens.B. Presence of Clostridium perfringens toxin.C. Presence of the brucellosis pathogen.D. Presence of escherichia antigen.E. Presence of salmonella Vi-antigen.

36. The woman during epidemic of flu has addressed the doctor with complaints of high body temperature, weakness, absence of appetite, pain in joints. For 10 days she was treated for flu. But infectionist has suspected brucellosis. Using what reaction is it possible to diagnose brucellosis?

A. Right.B. Wassermann test.C. Coombs test.D. Widal test.E. Ouhterlony.37. There was used biological test for diagnostics. In touch smear from organs of an

animal streptobacilli surrounded with a capsule were revealed. It gives the basis to diagnose:

A. Tularemia.B. Anthrax.C. Plague.D. Brucellosis.E. Streptococci pneumonia38. There is the patient with the presumptive diagnosis of acute pneumonia. In the

smear of sputum there are revealed chaotically located microorganisms of oval forms in length up to 2 microns bipolar stained. What the most likely diagnosis can be made on the basis of this data?

A. Lung plague.B. Streptococcal pneumonia.C. Staphylococcal pneumonia.D. Pneumonia caused by Klebsiella.E. Diphtheria.

39. Cattle raw material (a leather, a wool) should be checked up for the presence of the anthrax agent. For making this procedure we have to prepare soluble thermoresistant antigen in water-salt extract from raw material. What reaction may be used for this purpose?

A. Neutralizations.B. Precipitation in gel.C. Agglutinations.D. Indirect hemagglutination.E. Precipitation in liquid.40. In one of mountain settlements the mass destruction of rodents was observed.

Simultaneously inhabitants of this district have been ill. Illness was accompanied by fast

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rise of body temperature up to 400 C, the expressed intoxication, increase groin lymph nodes. In preparations (swabs from a cadaveric material) gram-negative bipolar stained oval rods were revealed. What microorganisms are agents of this infectious disease?

A. Staphylococci.B. The agent of plague.C. The agent of tularemia.D. The activator anthrax.E. Clostridia.

41Each of following statements concerning plague is correct EXCEPT:A. The causative organism, Y. pestis, is gram-negative rod with a very low ID50

B. Thereis an animal resorvoir for this diseas, including rodent C. The diagnosis must be serological because the organism does not grow in

cultureD. People should not handle dead wild animals since fleas associated with the

animals can transmit the disease

Real–life situation to be solved:1.The bubonic plague was suspected in a hunter. The doctor collected a puncture sample from a bubo. There were revealed small, gram-negative coccobacilli with tendency to bipolar staining. On the surface of MPA there was not growth of bacteria in a day.A. How can we explain this result?B. How can we prevent bacteriophages action?C. What examinations must doctor do to confirm the diagnosis of plague?2.The patient has severe cough with foamy, blood-streaked sputum, chest pain, high temperature (40 C). The smear was prepared from the sputum. There were revealed small, gram-nagative bacilli with delicate capsule. On the MPA R-form colonies like crumpled lace handkerchief twere grown.A. Can we make initial diagnosis of plague?B. Is it necessary to undertake urgent epidemiologic measures?C. What laboratory examinations is it necessary to do to determine the species of

Y. pestis.3.The group of doctors have to go to Uganda. It is known there are unforable epidemic situation, becouse hundreds of people have plague.A. What measures is it necessary to undertake for self-safety?B. Is it necessary to inoculate vaccine repeatedly if doctors should be in Uganda for

2 years? 4. After examination of the patient К., which complained of a high temperature,

headache, pain in muscles, oedematous lids, a hyperaemia of conjunctiva, bubo on left paraauricularis region, the doctor made the clinical diagnosis of oculobubonic tularemia. The discharge from the conjunctiva were sent to the laboratory of dangerous infection. Tested material was inoculated onto solid yolk medium, and was injected subcutaneously to white mice. The smear was prepares too. There were small gram-negative bacteria in the smear, there were not any signs of growth on nutrient medium, and the mouse died in 5 day after inoculation of material tested.

A. Whether do these results of bacteriological examination confirm the clinical diagnosis?

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B. What tests are necessary to carry out?5. In the patient with high temperature enlarged painless lymph node (bubo) was

found. The physician carried out allergic test with a tularin and took a blood for agglutination test. In 48 hours he has made the diagnosis of tularemia.

А. On what data has he made this conclusion?6. Burnet’s intracutaneous allergic test was carried out for milkmaids. In five of 30

assays the tests were was positive. All persons were vaccinated against brucellosis before.

А. Is it possible according to positive Burnet’s test make conclusion, that these people have brucellosis?

B. How is Burnet’s test carried out? When one can read its results?C. To what type of allergic responses does Burnet’s test belong to? D. What is brucellin?7. The patient К., has complaints of increased sweating, wavy fever, headache and

muscle pain, joint pain. The initial diagnosis of brucellosis was made. Laboratory examination for confirmation of the diagnosis was assigned.

А. Enumerate laboratory methods, which allow to confirm the diagnosis of brucellosis;

B. From what day of disease is it possible to perform Wright’s reaction?C. What criteria do testify about positive Wright’s reaction? D. How is it possible to differentiate the sick persons from vaccinated ones

according Wright’s reaction?8. A patients with initial diagnosis of anthrax was admitted to the infectious

diseases hospital. There was acute onset of disease. The patient had high temperature, and small vesicle 2-3 mm in diameter with serous fluid was appeared on the skin of right forearm. In a few day anthracic carbuncle was formed. It is known that three weeks ago the patients bought a new sheepskin coat in the market.

A. What disease may be in these patients?B. What microbiological methods can we use for examination?C. How can we determine the presence of B. anthracis on the surface of fur coat?

9. The tested material from the carbuncle was delivered to the bacteriological laboratory. There were revealed gram-positive rods with capsules in paires or in shot chains resembling bamboo canes with elbow-shaped articulation.

A. Can we make diagnosis according these signs?B. What methods of examinations can confirm your diagnosis?10. The patient complaints of high temperature (39 C), headache, general weakness.

On his forearm there is carbuncle of purple colour outside and black spot in the centre. The doctor made allergic test with anthracin. In 48 hrs hyperemia and infiltrate (4 mm in diameter) was appeared.

A. How can you value the results of this test?B. Can we refute the diagnosis of anthrax according this test?C. What another methods of examination can you propose to confirm the diagnosis

of anthrax?

7. List of literature:1.I. S. Gaidash, V.V. Flegontova, Microbiology, virology and immunology,

Lugansk, 2004, chapter19, p. 72-100.

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