IS LAB P1 QUIZZES COMPILATION involves combining soluble antigen with

soluble antibody to produce insoluble

ASSIGNMENT-RELATED QUIZ 1 complexes that are visible * precipitation
Competition between particulate ag (reagent) & is the initial force of attraction that exists
soluble ag (in specimen) for sites on reagent between a single Fab site onan antibody
ab. Lack of agglutination is the positive result. * molecule and a single epitope or determinant
agglutination inhibition site on the corresponding antigen * affinity
Soluble Ag combines with soluble Ab to represents the sum of all the attractive forces
produce visible complexes, is less sensitive between an antigen and an antibody. This
than agglutination * precipitation involves the strength with which a multivalent
antibody binds a multivalent antigen, and it is a
is a specific form of agglutination that involves measure of the overall stability of an antigen–
red blood cells. It has two common uses in the antibody complex. * avidity
laboratory: blood typing and the quantification
of virus dilutions * hemagglutination Antibodies are capable of reacting with
antigens that are structurally similar to the
are proteins that possess a specific affinity for original antigen that induced antibody
certain sugar molecules, any of a group of production. This is known as? * cross-reactivity
naturally occurring glycoproteins that cause
red blood cells (erythrocytes) to agglutinate, or Optimum precipitation occurs in the
clump together * hemagglutinins ________________, in which the number of
multivalent sites of antigen and antibody are
Antibodies belonging to the Ig____ class approximately equal. * zone of equivalence
agglutinate best at 30°C to 37°C. * G
antibody excess is also known as the _______
In ______ agglutination, antibody rather than phenomenon * prozone
the antigen is attached to a carrier particle. *
reverse passive Light scattering by ag-ab complexes. *
nephelometry
is the name given to systems using bacteria as
the inert particles to which antibody is is the most frequently used as carrier in
attached * coagglutination coagglutination * Staphylococcus aureus
The antihuman globulin test, also known as the is a laboratory technique used to separate DNA,
__________,is a technique that detects non- RNA, or protein molecules based on their size
agglutinating antibody by means of coupling and electrical charge. An electric current is
with a second antibody. It remains one of the used to move molecules to be separated
most widely used procedures in blood through a gel * electrophoresis
banking. *
Coomb's test is the second step in agglutination reactions *
lattice formation
Agglutination takes place because the
antihuman globulin is able to bridge the
distance between cells that Ig___ alone cannot LONG QUIZ: Ex. 1A, 1B, & 2
do. * G

The _________ antiglobulin test is used to What has happened in a titer, if tube Nos. 5–7
demonstrate in vivo attachment of antibody or show a stronger reaction than tube Nos.1–4? *
complement to an individual’s red blood cells. A. Prozone reaction
This test serves as an indicator of autoimmune B. Postzone reaction
hemolytic anemia, hemolytic disease of the C. Equivalence reaction
newborn,sensitization of red blood cells caused D. Poor technique
by the presence of drugs, or a transfusion In tubes Nos.1–4, insufficient antigen is present to
reaction * direct give a visible reaction because excess antibody
has saturated all available antigen sites. After
 dilution of antibody, tubes Nos.1–4 have the Postzone causes false-negative reactions in
equivalent concentrations of antigen and antibody antibody titers as a result of which of the
to allow formation of visible complexes following? *
a. Too much diluent added to test
Which statement best describes passive b. Excess antibody in test
agglutination reactions used for c. Excess antigen in test
serodiagnosis? * d. Incorrect diluent added to test
A. Such agglutination reactions are more rapid
because they are a single-step process What is the difference between nephlometry
B. Reactions require the addition of a second and turbidimetry? *
antibody a. There is no difference between the two assays,
C. Passive agglutination reactions require only in name
biphasic incubation b. Nephlometry is a newer example of
D. Carrier particles for antigen such as latex turbidimetry
particles are used c. Nephlometry measures light transmitted
Most agglutination tests used in serology employ through a solution, and turbidimetry measures
passive or indirect agglutination where carrier light scattered in a solution
particles are coated with the antigen. The carrier d. Nephlometry measures light scattered in a
molecule is of sufficient size so that the reaction of solution, and turbidimetry measures light
the antigen with antibody results in formation of a transmitted through a solution
complex that is more easily visible.
Agglutination and precipitation that is visible
The directions for a slide agglutination test depends on antigen–antibody ratios ________. *
instruct that after mixing the patient’s a. With antigen in excess
serumand latex particles, the slide must be b. With antibody in excess
rotated for2 minutes. What would happen if the c. That are equivalent
slide wererotated for 10 minutes? * d. All of the above
A. Possible false-positive result
B. Possible false-negative result Which of the following best describes
C. No effect agglutination? *
D. Depends on the amount of antibody present in a. A combination of soluble antigen with soluble
the sample Ab
Failure to follow directions, as in this case where b. A combination of particulate antigen with
the reaction was allowed to proceed beyond the soluble Ab
recommended time, may result in a false-positive c. A reaction that produces no visible end point
reading. Drying on the slide may lead to a possible d. A reaction that requires instrumentation to read
erroneous positive reading.
Reactions involving IgG may need to be
What is the main difference between enhanced for which reason? *
agglutination and precipitation reactions? * a. It is only active at 25°C.
a. Agglutination occurs between a soluble antigen b. It may be too small to produce lattice formation.
and antibody c. It has only one antigen-binding site.
b. Agglutination occurs when the antigen is d. It is not able to produce visible in vitro
particulate agglutination
c. Precipitation occurs when the antigen is
particulate Agglutination inhibition could best be used for
d. Precipitation occurs when both antigen and which of the following types of antigens? *
antibody are particulate a. Large cellular antigens such as erythrocytes
Precipitation reactions occur between soluble b. Soluble haptens
antigen and soluble antibody that produce a visible c. Bacterial cells
end result typically in the form of a visible line of d. Antigen attached to latex particles
precipitate. Agglutination reactions occur when the
antigen is particulate or coated on a particulate All of the following could be used to enhance
such as latex beads. an agglutination reactions except *
a. increasing the viscosity of the medium.
b. using albumin.
c. increasing the ionic strength of the medium. a. Centrifugation
d. centrifugation. b. Treatment with proteolytic enzymes
In which of the following circumstances would c. Acidifying the mixture
the indirect Coombs’ test be employed? * d. Using colloids
a. Identification of the ABO blood groups
b. Identification of cold-reacting antibody Flocculation procedures differ from latex
c. Identification of an unexpected IgG antibody agglutination procedures because: *
d. Identification of hemolytic disease of the a. Antigen is bound to a carrier.
newborn b. Antibody is bound to a carrier.
c. Soluble antigen reacts with antibody.
Which of the following correctly describes d. Flocculation procedures are only qualitative.
reverse passive agglutination? *
a. It is a negative test. The effect of competing antibodies seeking to
b. It can be used to detect autoantibodies. attach to antigen sites is called: *
c. It is used for identification of bacterial antigens. to antigen sites is called:
d. It is used to detect sensitization of red blood a. Prozone phenomenon
cells. b. Ionic strength
c. Steric hindrance
Agglutination of dyed bacterial cells represents d. Sensitization
which type of reaction? *
a. Direct agglutination In the hemagglutination technique, antihuman
b. Passive agglutination globulin is used as an enhancement medium to
c. Reverse passive agglutination detect _______antibodies. *
d. Agglutination inhibition a. IgM
b. IgG
In an agglutination reaction, if cells are not c. IgD
centrifuged long enough, which of the following d. IgE
might occur? *
a. False-negative result Match the following grades of agglutination
b. False-positive result with the appropriate description.
c. No effect mixed-field
d. Slight effect but can be ignored 1+
2+
For which of the following tests is a lack of 4+
agglutination a positive reaction? * a. all the erythrocytes are combined into 1 solid
a. Hemagglutination aggregate; clear supernantant
b. Passive agglutination b. few isolated aggregates; supernatant appears
c. Reverse passive agglutination red
d. Agglutination inhibition c. medium-sized aggregates; clear supernatant
d. a few small aggregates; turbid and reddish
The quality of test results in an agglutination supernatant
reaction depends on all the following except: * e. several large aggregates; clear supernatant
a. Duration of incubation
b. Amount of antigen conjugated to the carrier Sensitization: *
c. Avidity of antigen conjugated to the carrier a. Is the first phase of agglutination
d. Whether the carrier is artificial or biological b. Represents the physical attachment of antibody
molecules to antigens on the RBC membrane
The prozone phenomenon can result in a (an): * c. Is an irreversible reaction
a. False-positive reaction d. Both a and b
b. False-negative reaction
c. Enhanced agglutination The most common laboratory method for
d. Diminished antigen response detecting hCG is: *
a. Latex agglutination
All the following are methods that can be used b. Enzyme-linked immunosorbent assay
to enhance the agglutination of IgG antibodies c. Immunofluorescence
except: * d. Antibody titration
In the latex agglutination method for the
detection of hCG, no agglutination indicates
the: *
a. Absence of hCG
b. Presence of hCG
c. Absence of hCG, a positive test
d. Presence of hCG, a negative test

There are two figures given below, Figure A and

Figure B, please identify the phase or step
invloved in Figure B. *

Agglutination inhibition

Identify the type of agglutination in the figure

given below *

Lattice formation

Identify the type of agglutination as shown in

Coagglutination
the figure given below *
Identify the type of antiglobulin test as shown in
the figure given below: *

Reverse passive agglutination

Identify the type of agglutination as shown in

the figure given below *

Indirect antiglobulin test

Match each term to its definition: * identity, non-identity, partial identity
precipitation
agglutination When soluble antigens diffuse in a gel that
coagglutination contains antibody,in which zone does optimum
flocculation precipitation occur? *
hemagglutination a. Prozone
a. Aggregation of particulate test antigens b. Zone of equivalence
b. Aggregation of soluble test antigens c. Postzone
c. Uses antibodies bound to a particle to enhance d. Prezone
visibility of agglutination
d. Agglutination of erythrocytes in tests for In a precipitation reaction, how can the ideal
antibody detection antibody be characterized? *
e. Based on the interaction of soluble antigen with a. Low affinity and low avidity
antibody, resulting in formation of a precipitate of b. High affinity and low avidity
fine particles c. High affinity and high avidity
d. Low affinity and high avidity
A classic technique for the detection of viral
antibodies is: * Which of the following refers to the force of
a. Passive hemagglutination attraction between an antibody and a single
b. Indirect hemagglutination antigenic determinant? *
c. Hemagglutination inhibition a. Affinity
d. Latex particle agglutination b. Avidity
c. Van der Waals attraction
Artificial or biological carriers that can be used d. Covalence
in anagglutination reaction include: *
a. Latex particles Which of the following statements apply to rate
b. Colloidal charcoal nephelometry? *
c. Erythrocytes coated with antigen in a constant a. Readings are taken before equivalence is
amount reached.
d. All of the above b. It is more sensitive than turbidity.
c. Measurements are time dependent.
Agglutination can be used to enhance reactions d. All of the above
by all the following means except: *
a. Decreasing ionic strength of the reaction In which zone might an antibody-screening test
b. Centrifugation be false negative? *
c. Increasing pH of the reaction a. Prozone
d. Using colloids and antihuman globulin b. Zone of equivalence
c. Postzone
Identify the Ouchterlony diffusion patterns d. None of the above
presented below, A_______, B________,
C_________ * If crossed lines result in an Ouchterlony
immunodiffusion reaction with antigens 1 and
2, what does this indicate? *
a. Antigens 1 and 2 are identical.
b. Antigen 2 is simpler than antigen 1.
c. Antigen 2 is more complex than antigen 1.
d. The two antigens are unrelated.

the following are advantages of using latex

particles as carriers except *
latex particles are inexpensive, stable and are not
subject to cross-reactivity
a large number of antibody molecules can be
bound to the surface of latex particles, so the
number of antigen binding sites is large
the large particle size of latex, facilitates reading it depends on the reagents used
of the test none of the choices
all of the above
none of the above If there is 19 ml of diluent in the tube and a 1 ml
sample is added, what is the dilution of the
the following are roles of carrier particles that sample? *
are used in passive agglutination reactions, 1/200
except * 1/20
they are used to visualize the Ag-Ab reaction that 1/0.05
has taken place / enhances the visibility of the 0.05
reaction none of the choices
provide the advantage of consistency, uniformity,
and stability How are serial dilutions expressed? *
weakly bridges the gap between the Ag and the percentages
Ab fractions
all of the above decimals
none of the choices integers
all of the choices above
none of the choices

LONG QUIZ: Ex. 3, 4A, & 4B If there is a 9.9 ml diluent in the tube, and a 0.1
ml sample is added into the tube, what is the
final dilution after it is diluted 3 times? *
What is the titer in tube No. 8 if tube No. 1 is 0.0001
undiluted and dilutions are doubled? * 0.1
A. 64 0.01
B. 128 0.001
C. 256
D. 512 Widal agglutinaton test is a serologic means of
The antibody titer is reciprocal of the highest detecting the presence of *
dilution of serum giving a positive reaction. For trench fever
doubling dilutions, each tube has one half the Q fever
amount of serum as the previous tube. Because typhoid fever
the first tube was undiluted (neat), the dilution in Lassa fever
tube No. 8 is (1/2)7 and the titer equals 27 or 128. yellow fever
the following are true regarding the Widal test * The following are true regarding Widal
it detects agglutinating antibodies against the O agglutination test, as developed by F Widal in
and H antigens of S. typhi 1896, except *
it measures the capacity of antibodies against utilises a suspension of killed Salmonella typhi as
LPS and flagella in the serum of individuals with antigen
suspected typhoid fever to agglutinate cells of S. The test was based on demonstrating the
typhi presence of agglutinin (antibody) in the serum of
a four-fold increase in antibody titre, indicates a an infected patient,
positive result the index of suspicion for the presence of typhoid
Like most serologic tests, a false-negative Widal fever increases when positive agglutination is
test may occur early in the course of illness, and a demonstrated during the acute and convalescent
false-positive Widal test may result from past period of infection with evidence of a four-fold rise
infection or from previous exposure to cross- of antibody titre
reactive antigens or vaccination In developed countries, the use of Widal
all of the above agglutination as a laboratory tool to aid in the
none of the given choices diagnosis of typhoid fever during the acute phase
of the illness, has largely been abandoned
Serial dilutions must transfer the same amount all of the choices
of volume to each well. * none of the choices
true
false
the test suffers from serious cross-reactivity with unless the sensitivity and specificity of the test for
other infectious agents, it may produce false- the specific laboratory and patient population are
positive results known, as well as predictive values. Even in the
extreme case of a high titre in a single Widal
The Widal test reaction involves the use of agglutination test, the causative organism may
bacterial suspensions of S typhi and S often be due to other species of Salmonella, rather
paratyphi ‘A’ and ‘B’, treated to retain only the than S typhi.
‘O’ and ‘H’ antigens. Which of the given
statements below is/are true? * it is the gold standard for definitive diagnosis of
the IgM somatic O antibody appears first and typhoid fever *
represents the initial serologic response in acute Widal slide aggutination test
typhoid fever Widal tube agglutination test
the IgG flagella H antibody usually develops more bacteriological culture
slowly but persists for longer immunochromatographic test
the Widal slide test is rapid and is used as a none of the choices above
screening procedure
the tube agglutination test requires much more Widal test cannot be expected to give a reliable
technical work than the rapid slide test, and is a diagnostic result in endemic regions for the
macroscopic test. following reasons, except *
the tube test is useful to clarify erratic or equivocal repeated exposures to S typhiin endemic regions
agglutination reactions obtained by the more rapid difficulty in establishing a steady-state baseline
slide test. titre for the population
all of the given choices above cross-reactivities with other non-Salmonella
none of the choices organisms
the inherent variabilities of the test
the following diseases (except one) have been lack of reproducibility of the test result.
shown to exhibit cross-reactivity in typhoid all of the choices
endemic regions, and these cross-reactions none of the choices
increase the error rate of the result of the Widal
test * base your answer on the data given |if the
miliary tuberculosis, endocarditis number of dilutions is 10, and the diltuion factor
ottitis externa is 5: 1, what is the dilution factor of the 6th
chronic liver disease solution with respect to starting solution? *
malaria 625:1
dengue 3125:1
brucellosis 15625:1
78125:1
In endemic typhoid regions, a single testing of a
serum specimen for Widal agglutinin cannot
provide a reliable diagnosis due to: *
other infectious agents such as malaria. MINI QUIZ: Ex. 5A, 5B, and 5C
repeated exposure to small inocula ofS typhi or to
otherSalmonella spp that contain type 9 or 12 A 32-year-old man presents with a 4-day history
antigens of painless penile lesions (Figure shown
previous typhoid fever immunisation below). His sex partners are men and he has
all of the choices given above had 2 partners in the last 6 months. Physical
none of the choices examination reveals 3 non-tender ulcers on the
lateral aspect of the penile shaft and firm
it should be stressed that a single Widal lymphadenopathy in the right inguinal region
agglutination test has no diagnostic that is nontender. Oral examination and skin
significance in an endemic region * inspection are normal. He has no neurologic
true symptoms. A clinical diagnosis of syphilis is
false strongly suspected; nontreponemal and
According to Hoffman et al,10 the results of a treponemal serologic. Based on the information
single Widal test, tube dilution, micro-agglutination at this point, how would you clinically stage
or slide agglutination are virtually un-interpretable syphilis in this man? *
 The degree of elevation in the enzyme
immunoassay (EIA) titer can accurately
distinguish primary from secondary syphilis
A reactive treponemal test does not require any
further confirmatory testing
A reactive nontreponemal test should be
confirmed by a treponemal test
A reactive nontreponemal test should be confirmed
by a treponemal test. Serologic testing remains the
primary tool for diagnosis in most patients with
syphilis and these tests include “nontreponemal”
and “treponemal” tests. Although Polymerase
primary syphilis
Chain Reaction (PCR) testing is sometimes used
secondary syphilis
for research purposes, there is no FDA-approved
tertiary syphilis
PCR test for T. pallidum at present. The sensitivity
latent syphilis
of syphilis testing in persons with secondary
Primary Syphilis: The characteristic finding
syphilis is very high. Treponemal Serologic Tests:
associated with primary syphilis is the formation of
The treponemal serologic tests include the enzyme
a primary lesion or "chancre" at the site of
immunoassay (EIA), chemiluminescence
inoculation of T. pallidum. A chancre, when
immunoassay (CIA), Treponema pallidum particle
observed, typically manifests about 3 weeks (range
agglutination (TP-PA), and fluorescent treponemal
10 to 90 days) after acquisition of T. pallidum. A
antibody absorption (FTA-ABS). These tests
chancre typically progresses from a papule to an
measure antibody directed against T. pallidum
ulcer, which is often painless, indurated, well
antigens and are reported as a qualitative result,
circumscribed, round to oval in shape, with a clean
either reactive (positive) or nonreactive (negative).
base. Regional firm, nontender, lymphadenopathy
Nontreponemal Serologic Tests: The most
can develop in proximity to primary syphilitic
commonly used nontreponemal tests include Rapid
lesions (usually bilaterally). Because the ulcer is
Plasma Reagin (RPR) and Venereal Disease
often painless, symptoms can go unnoticed.
Research Laboratory (VDRL). These test are
Chancres are typically found in the genital region,
based on the observation that persons with syphilis
but can also occur in the mouth, and rarely, on the
generate antibodies that react to an antigen
skin at the site of inoculation. Therefore, a thorough
mixture containing cardiolipin extracted from beef
physical exam should be performed when primary
heart (in alcohol), cholesterol, and lecithin. The
syphilis is suspected. Although most persons with
human antibodies that form to this antigen mixture
primary syphilis have a solitary chancre, some
are referred to as "Reagin" or "anticardiolipin
individuals with primary syphilis will present with
antibodies." Since these tests measure human IgM
multiple anogenital lesions.
and IgG antibodies to the cardiolipin antigens, they
are not specific for T. pallidum. Nontreponemal test
A 19-year-old woman presents for a new
results are reported with a qualitative result
maculopapular rash on her trunk, which
(reactive or nonreactive) and positive results are
includes the palms of her hands and soles of
then analyzed to determine a quantitative titer. To
her feet. She has no other medical problems,
determine the quantitative titer, serial dilutions are
takes no medications, and denies illicit drug
performed, either in test tubes, plates, or cards,
use. She has never been tested for sexually
with a quantitative titer usually correlating with
transmitted infections (STIs) before. She has
disease activity.
had three male partners in the past 6 months
with intermittent condom use. One of her male
A 45-year-old man is screened for syphilis and
partners also has sex with men. A clinical
has a positive Treponema pallidum-specific
diagnosis of secondary syphilis is make and
enzyme-linked immunoassay (EIA). The
laboratory testing is ordered to confirm the
laboratory performs a reflexive Rapid Plasmin
diagnosis of syphilis. Which one of the
Reagin (RPR) test that is nonreactive. Tests for
following is TRUE regarding the laboratory
HIV, Neisseria gonorrhoeae, and Chlamydia
diagnosis of syphilis in this woman? *
trachomatis are negative. He has no medical
Approximately 50% of persons with secondary
problems, takes no medications, and does not
syphilis have a negative Treponema pallidum
use illicit drugs. He has been sexually active
enzyme immunoassay (EIA)
with the same female partner for the past 3
years. He has no prior history of any sexually with treponemal tests, such as an enzyme
transmitted infections, and has never been immunoassays (EIA) may be slightly higher but a
tested or treated for syphilis. He is nonreactive treponemal antibody assay does not
asymptomatic and the physical examination is rule out the diagnosis of primary syphilis.
normal. What is most appropriate next step in The recommended regimen in the 2015 STD
the management of this man? * Treatment Guidelines for adults with primary and
Repeat both the EIA and the RPR secondary syphilis is given as 2.4 million units
Send an alternative nontreponemal test intramuscular (IM) in a single dose. Treatment of
Send an alternative treponemal test primary and secondary syphilis for patients with
No further work-up at this time documented allergy to penicillin has limited
available data. Small studies and clinical
A 25-year-old man presents for evaluation of experience suggest that regimens of doxycycline
new nontender penile lesion (Figure shown (100 mg orally twice daily for 14 days) or
below). He has no other symptoms. He has no tetracycline (500 mg four times daily for 14 days)
medical problems, denies medications or illicit are acceptable alternatives for nonpregnant,
drugs and has no antibiotic allergies. He penicillin-allergic persons who have primary or
reports insertive-only anal intercourse with secondary syphilis. Doxycycline is preferable to
multiple male partners and rare condom use. tetracycline because of more convenient dosing
Physical examination reveals a 1 cm, nontender and fewer gastrointestinal side effects.
ulcer on the dorsal surface of his penis and no Azithromycin is no longer an option for treating
other significant findings. Further testing syphilis due to the emergence of T. pallidum
reveals a positive syphilis enzyme macrolide resistance.
immunoassay (EIA) and a positive Rapid
Plasma Reagin (RPR) at a titer of 1:32. He has A 31-year-old transgender woman is diagnosed
never been diagnosed with or treated for with secondary syphilis infection after
syphilis in the past. An HIV test returns presenting to an STD clinic 2 days prior with
negative. What is the appropriate therapy for mouth lesions and an erythematous rash on her
this man? * chest, back, legs, and hands. At that time she
denied any other symptoms and a neurologic
examination was normal. Laboratory studies
show a positive treponemal enzyme
immunoassay (EIA); the nontreponemal Rapid
Plasma Reagin (RPR) is pending. Vaginal and
pharyngeal tests for Neisseria gonorrhea and
Chlamydia trachomatis are negative. An HIV
antigen-antibody test is negative. The decision
is made to treat her for secondary syphilis, but
she informs you she has a history of
anaphylaxis to penicillin. What is the most
Amoxicillin 500 mg orally three times a day for 7 appropriate for treatment of secondary syphilis
days for this woman who has a severe penicillin
Azithromycin 2 grams orally once allergy? *
Benzathine penicillin G 2.4 million units Azithromycin 2 g orally single dose
intramuscular in a single dose Clindamycin 450 mg four times a day for 10 days
Benzathine penicillin G 7.2 million units total, Doxycycline 100 mg orally twice daily for 14 days
administered as 3 doses of 2.4 million units Levofloxacin 500 mg once daily for 10 days
intramuscular each at 1-week intervals This 31-year-old woman has been diagnosed with
For this 25-year-old man, the combination clinical secondary syphilis and would typically be treated
findings and positive syphilis serologic tests are with a single dose of intramuscular benzathine
consistent with a diagnosis of primary syphilis. penicillin G 2.4 million units, but she has a history
Dark-field microscopy of lesion exudate or tissue is of severe penicillin allergy and thus an alternative
the definitive method for diagnosing early syphilis; to penicillin should be used. There are limited data
this test, however, is rarely available, as most on the treatment of primary and secondary syphilis
facilities do not have dark-field microscopy. Up to for persons with documented allergy to penicillin.
20 to 30% of individuals with a chancre will have Accordingly, any individual with syphilis who is not
negative nontreponemal serologic tests; the yield treated with penicillin should receive close follow-
up after treatment. The following summarizes and 24 months after a diagnosis of primary or
treatment options for persons with primary or secondary syphilis. It is important to use the same
secondary syphilis and a history of penicillin type of quantitative nontreponemal test when
allergy. comparing follow-up titers to accurately monitor
response to treatment or to evaluate for reinfection
Doxycycline or Tetracycline: Small studies and with Treponema pallidum. For example, if the initial
clinical experience suggest that regimens of diagnostic testing utilized a serum quantitative
doxycycline 100 mg orally twice daily for 14 days Rapid Plasma Reagin (RPR), as was done in the
and tetracycline (500 mg four times daily for 14 patient in this case, then subsequent serum testing
days) are acceptable alternatives for nonpregnant, should utilize RPR testing.
penicillin-allergic persons who have primary or
secondary syphilis. Doxycycline is preferable to A 20-year-old man who is receiving tenofovir
tetracycline because of the twice versus four times DF-emtricitabine for HIV preexposure
daily dosing and fewer gastrointestinal side effects. prophylaxis (PrEP) is seen for a routine follow-
up visit. Screening laboratory tests show a
A 24-year-old man presents with a 3-day history positive treponemal enzyme immunoassay
of a diffuse rash. He reports having 7 sex (EIA) and a positive Rapid Plasma Reagin
partners, all male, within the last 3 months. (RPR), with a titer of 1:16. Tests for HIV and
Physical examination shows an erythematous other sexually transmitted infections (STIs) are
macular rash on his chest, back, arms, and negative. He does not have any symptoms and
palms. He has no visual or neurologic does not recall any symptoms during the past
complaints and a neurologic examination is year that were consistent with syphilis. He
normal. A clinical diagnosis of secondary states he has never been diagnosed with
syphilis is made. Laboratory studies are syphilis, nor has he received treatment for
ordered and he is treated with a single syphilis in the past. He was screened with a
intramuscular dose of 2.4 million units of treponemal EIA test 6 months ago, which was
benzathine penicillin G. Subsequently, the negative. A physical examination does not
baseline laboratory studies show a positive show any abnormalities. He does not have any
treponemal enzyme immunoassay (EIA), a antibiotic allergies. What is the best
Rapid Plasma Reagin (RPR) titer of 1:512, and a management of syphilis in this 20-year-old
negative HIV-1/2 antigen-antibody test.When man? *
should repeat syphilis serologic evaluation be 2/2
performed? * No treatment is necessary since he is
No follow-up is needed since he received asymptomatic
recommended therapy Benzathine penicillin G 2.4 million units
6 and 12 weeks intramuscular in a single dose
6 and 12 months Benzathine penicillin G 7.2 million units total,
12 and 24 months administered as 3 doses of 2.4 million units
Follow-up laboratory monitoring is an essential intramuscular each at 1-week intervals
component of management of syphilis. For persons Ceftriaxone 1 g intramuscular daily for 10 days
without HIV who are treated for primary or The term latent syphilis refers to persons who have
secondary syphilis, the 2015 STD Treatment acquired Treponema pallidum infection but do not
Guidelines advise quantitative nontreponemal have any active signs or symptoms associated with
serologic tests should be checked at 6 and 12 syphilis. Thus, this 20-year-old man has latent
months after treatment. At these visits, a clinical syphilis based on the combination of a positive
evaluation should also be performed. All persons serologic syphilis test (both EIA and RPR) and the
diagnosed with syphilis should have an HIV test absence of any clinical manifestations of primary,
performed, unless they already have a known secondary, or tertiary disease. Latent syphilis is
diagnosis of HIV. Of note, for persons who test divided into the categories of early latent or late
negative for HIV, many experts would favor repeat latent disease. Early Latent Syphilis: Persons who
screening (for bacterial sexually transmitted do not currently have symptoms, but during the
infections and HIV) in 3 months for any person with year preceding the diagnosis of syphilis had any
a new diagnosis of syphilis. one of the following: A documented seroconversion
For persons with HIV, the 2015 STD Treatment or a sustained (longer than 2 weeks) fourfold or
Guidelines advise clinical and syphilis greater increase in nontreponemal test titers; or
nontreponemal serologic evaluation at 3, 6, 9, 12, An unequivocal history of symptoms of primary or
secondary syphilis; or A sex partner documented to 12 to 24 months
have primary, secondary, or early latent syphilis; or All persons diagnosed with syphilis should have an
Reactive nontreponemal and treponemal tests with HIV test performed, unless they already have a
the only possible exposure for syphilis occurring known diagnosis of HIV. Follow-up laboratory
during the previous 12 months. monitoring is an essential component of
Late Latent Syphilis: Persons with asymptomatic management of syphilis. The 2015 STD Treatment
syphilis who do not meet the criteria for early latent Guidelines advise obtaining quantitative
syphilis are considered to have late latent syphilis. nontreponemal serologic test at 6, 12, and 24
months after treatment for latent syphilis (either
The patient in this case clearly has early latent early latent or late latent). At these visits, a clinical
syphilis since he has a current positive syphilis evaluation should also be performed. For HIV
serologic test without current clinical symptoms and seropositive individuals with latent syphilis, the
a negative syphilis serologic test 3 months prior. recommended follow-up is the same except that an
The 2015 STD Treatment Guidelines recommend 18-month visit is also included. Of note, many
treating early latent syphilis the same as for experts would favor repeat STI screening at 3
primary and secondary syphilis—one dose of months for any person with a new diagnosis of
intramuscular benzathine penicillin G (2.4 million syphilis, regardless of HIV status. In addition, for
units). For patients with early latent syphilis and persons who are HIV negative at the time of the
penicillin allergy, the approach is the same as with syphilis diagnosis, most experts would also
primary or secondary syphilis—doxycycline 100 mg recommend repeating the HIV testing at this 3-
twice daily for 14 days or tetracycline (500 mg month follow-up visit. The following outlines the
orally four times daily for 14 days). Most experts different possible serologic responses in persons
prefer doxycycline in this setting due to better with latent syphilis based on the nontreponemal
tolerance and fewer daily doses than with titer change.
tetracycline. Persons with a penicillin allergy in Probable Response to Treatment: The expected
whom compliance with oral therapy or follow-up response to treatment is a fourfold decline in a
cannot be assured should undergo penicillin nontreponemal titer (using the same
desensitization and then receive treatment with nontreponemal test) at 12-24 months after
benzathine penicillin. The effectiveness of treatment for latent syphilis. Many patients will
alternatives to penicillin in the treatment of early have a fourfold decline in nontreponemal tests
syphilis has not been well documented. sooner than the 2-year mark, indicating a response
to treatment. Nontreponemal titers might even
A 31-year-old man presents to the clinic for become nonreactive with time.
routine sexually transmitted infection (STI) Probable Failure: Persons treated for syphilis are
screening. He is asymptomatic and reports 10 considered likely to have failed therapy (or have
male sex partners during the past year. been reinfected) if any of the following scenarios
Laboratory tests show a positive treponemal exist: (1) they have persistent or recurrent signs or
enzyme immunoassay (EIA) and a positive symptoms; (2) there is a sustained (longer than 2
Rapid Plasma Reagin (RPR) at a titer of 1:64. weeks) fourfold increase in nontreponemal test
Tests for HIV and other STIs are negative. His titer; or (3) nontreponemal test titers that were
last screening for STIs (including syphilis) was initially high (at least 1:32) fail to decline fourfold
2 years ago. He has never had a history of within 12-24 months after therapy for latent
syphilis or other bacterial STIs. Given this syphilis. With any of these situations, cerebrospinal
patient’s lack of symptoms and previous tests fluid analysis should be performed and treatment
for syphilis were longer than 1 year ago, the based on these findings—if negative, retreat for
diagnosis of late latent syphilis is made, and he latent syphilis and if positive treat for neurosyphilis.
is treated with three doses of intramuscular Possible Failure: Nontreponemal test titers that
benzathine penicillin G 2.4 million units, were initially low (1:4 or lower) and fail to decline
administered at 1-week intervals (total dose of fourfold within 12 to 24 months after therapy for
7.2 million units). What is the acceptable time latent syphilis, but do not increase, might indicate
frame to expect the nontreponemal serologic treatment failure. Additional clinical and serological
tests to decline appropriately (fourfold) without follow-up is necessary since the optimal
being concerned for treatment failure? * management is unclear. In this situation, most
1 to 2 months experts do not recommend repeat treatment or
3 to 6 months examination of cerebrospinal fluid.
6 to 12 months
A 25-year-old man is diagnosed with secondary relapsing fever and Lyme disease. The
syphilis based on a diffuse maculopapular rash management of this reaction consists of supportive
and a Rapid Plasma Reagin (RPR) titer of 1:256. therapy with antipyretics and intravenous fluids (if
He is given an intramuscular dose of 2.4 million needed). Pre-medicating with antipyretics or
units of benzathine penicillin G in the clinic, but corticosteroids before an antimicrobial dose does
approximately 4 hours after receiving the dose not prevent the Jarisch-Herxheimer reaction. When
of penicillin, he returned with complaints of considering a possible diagnosis of the Jarisch-
fever, headache, myalgia, dizziness, and Herxheimer reaction, the patient should be
intensification of his rash. Physical examination evaluated for hives or difficulty breathing, either of
shows a temperature of 38.5°C, blood pressure which would suggest a severe possible
96/74 mmHg, accentuation of the rash, but no antimicrobial allergic reaction. Distinguishing
evidence of hives, oropharyngeal swelling, or Jarisch-Herxheimer reaction from an allergic
wheezing. What is the most likely explanation antimicrobial reaction is critical since the acute
for the patient’s symptoms? * management is entirely different. In addition, in
Mild type IV anaphylactic reaction to penicillin contrast to persons who have a severe allergic
Allergic reaction to benzathine reaction to an antimicrobial, persons who have the
Prozone reaction Jarisch-Herxheimer reaction can receive additional
Jarisch-Herxheimer reaction therapy with the same antimicrobial, if needed.
The 25-year-old man presented in this case is very
likely experiencing a Jarisch-Herxheimer reaction A 43-year-old man with a positive Rapid Plasma
after initiating treatment of his syphilis infection. Reagin (RPR) test (titer of 1:64) is referred for
Most individuals who have a Jarisch-Herxheimer further evaluation and treatment of syphilis. He
reaction will experience symptoms, but not typically reports having a total body rash and low-grade
as severe as described in this man. Persons fever that resolved about 3 months prior. He
receiving treatment for syphilis should be informed reports severe headaches in the past week with
about the potential for a Jarisch-Herxheimer nausea, vomiting, and mild photophobia. The
reaction. The time course and physical examination headache has not resolved with over-the-
findings are not consistent with an anaphylactic counter medications and he has no history of
reaction to penicillin or a reaction to benzathine. headaches. He has not had prior testing or
The Prozone reaction is a term related to treatment for syphilis. A recent HIV antigen-
laboratory diagnosis of syphilis, not a clinical antibody test is negative. A lumbar puncture is
manifestation. The Jarisch-Herxheimer reaction is performed, with cerebrospinal fluid analysis, to
a self-limited systemic reaction associated with evaluate for neurosyphilis.Which one of the
initiation of antitreponemal therapy that typically following statements is TRUE regarding
begins within 4 hours after receiving the first dose cerebrospinal fluid (CSF) laboratory studies in
of antimicrobial therapy, peaks in about 8 hours, diagnosing neurosyphilis? *
and gradually resolves within 24 hours. The The CSF Venereal Diseases Research Laboratory
Jarisch-Herxheimer reaction is the manifestation of (VDRL) test is highly specific; it is the preferred
transient release of inflammatory cytokines in test for confirming a suspected diagnosis of
response to spirochete lipoproteins lysed by neurosyphilis
antimicrobial therapy. The most common The CSF Rapid Plasma Reagin (RPR) test is the
symptoms associated with the Jarisch-Herxheimer most sensitive and specific test for diagnosing
reaction include fever, chills, tachycardia, myalgias, neurosyphilis; it is the preferred test both for
vasodilatation with flushing, accentuation of the confirming and excluding neurosyphilis
skin rash (if present prior to treatment), and The CSF fluorescent treponemal antibody
dizziness (from mild-moderate hypotension). In absorbed (FTA-ABS) test has poor sensitivity and
addition, there are reports of this reaction no role in diagnosing neurosyphilis
precipitating labor in pregnant women. The Jarisch- There is no role for CSF treponemal or
Herxheimer reaction can occur after initiating nontreponemal tests in diagnosing neurosyphilis
treatment for syphilis at any stage, but it is most The evaluation of persons with a new serologic
likely to develop in persons treated for early diagnosis of syphilis (or suspected syphilis) should
syphilis, especially those with secondary syphilis incorporate a neurologic review of symptoms and
who have high nontreponemal test titers neurologic physical examination. This includes
(presumably because of higher spirochete burden). identifying symptoms of ocular or otosyphilis. The
The Jarisch-Herxheimer reaction has also been patient in this case, with a confirmed laboratory
observed with other spirochete illnesses, such as diagnosis of syphilis and new headache, nausea,
vomiting, and photophobia, has a clinical A 22-year-old woman is diagnosed with
presentation highly concerning for neurosyphilis, neurosyphilis after presenting with stroke-like
specifically syphilitic meningitis. The 2015 STD symptoms and a positive treponemal enzyme
Treatment Guidelines recommend performing a immunoassay (EIA) and a positive Rapid
lumbar puncture with evaluation of the Plasma Reagin (RPR) test (titer of 1:128). A
cerebrospinal fluid (CSF) in any of the following lumbar puncture is performed with
situations: cerebrospinal fluid analysis that shows protein
Neurologic or ophthalmic signs or symptoms in any of 64 mg/dL, white blood cell count of 18 (80%
stage of syphilis lymphocytes), a red blood cell count of 0, and a
Evidence of active tertiary syphilis affecting other positive Venereal Disease Research Laboratory
parts of the body (VDRL) titer of 1:64. Tests for other causes of
Treatment failure in any stage of syphilis stroke, as well as an HIV test are negative. She
The diagnosis of neurosyphilis is usually based on has a 2-year history of engaging in
a combination of several factors: (1) presence of transactional sex, but has never previously
reactive serologic test results, (2) neurologic signs been tested or treated for syphilis. She denies
and/or symptoms, and (3) CSF abnormalities that any history of allergic reactions to antibiotics.
include elevated protein, pleocytosis, or a reactive What is the most appropriate antimicrobial
Venereal Disease Research Laboratory (VDRL). therapy for treatment of neurosyphilis in this
The criteria used for CSF abnormalities depend on woman? *
the HIV serostatus of the individual. No single test Ceftriaxone 1 g intramuscular once daily for 5
or finding alone is considered diagnostic for days, followed by doxycycline 100 mg orally twice
neurosyphilis. Although the 2015 STD Treatment daily for 14 days
Guidelines do not provide clear cut-offs for Ceftriaxone 1 g intramuscular once daily for 10 to
elevated cerebrospinal fluid protein and cell count 14 days
in HIV-negative individuals, some experts have Benzathine penicillin G 7.2 million units total,
recommended using the following cut-offs: (1) administered as 3 doses of 2.4 million units
white blood cell count greater than 5 cells/mm3, (2) intramuscular each at 1-week intervals
protein greater than 45 mg/dL, or (3) a reactive Aqueous crystalline penicillin G 18 to 24 million
CSF-VDRL. The elevation in CSF white blood cell units per day, administered as 3 to 4 million units
count usually shows lymphocyte predominance. intravenous every 4 hours (or continuous
The criteria used to define CSF abnormalities are infusion), for 10 to 14 days
different for persons with HIV infection. The This 22-year-old woman has a clear
cerebrospinal fluid VDRL test has high specificity diagnosis of neurosyphilis. The 2015 STD
and is valuable for confirming a diagnosis of treatment guidelines recommended regimen for
neurosyphilis. The sensitivity of the CSF VDRL, neurosyphilis is a 10-to-14-day course of
however, is not optimal and the sensitivity of the intravenous penicillin G; the alternative regimen, in
cerebrospinal fluid Rapid Plasma Reagin (RPR) a person whom is expected to be adherent with the
test is even lower. When using a nontreponemal treatment plan, is daily intramuscular procaine
test to evaluate for neurosyphilis, the CSF VDRL is penicillin given in conjunction with probenecid (to
preferred over the CSF RPR. When analyzing boost the levels of penicillin) for 10 to 14 days.
CSF, the VDRL should be chosen as the initial test After completing the recommended 10-to-14-day
—if positive (in the setting of neurologic neurosyphilis treatment, benzathine penicillin G 2.4
abnormalities) the diagnosis of neurosyphilis is million units IM once per week for up to 3 weeks
confirmed. False-positive VDRL may be seen in can be considered to provide a total duration of
blood tinged CSF in patients with high VDRL or therapy comparable to the duration with late latent
RPR titers. Given the relatively low sensitivity of the syphilis.
VDRL, a negative test does not exclude the
diagnosis of neurosyphilis. In contrast, the CSF A 26-year-old woman presents to her family
fluorescent treponemal antibody-absorption (FTA- medicine physician for a routine pregnancy
AB) test has high sensitivity for neurosyphilis and visit. This is her first pregnancy medical
may be useful for excluding a diagnosis of evaluation and she estimates she is 16 weeks
neurosyphilis. Therefore, if there is a concern for pregnant based on her last menstrual period.
neurologic involvement in a patient with a negative As part of this initial evaluation, you discuss
CSF VDRL, obtain a cerebrospinal fluid FTA-AB prenatal screening. What are the current
test may provide useful additional information. recommendations for syphilis screening in
pregnant women? *
Routinely screen all women 25 years of age and A. Highest serum dilution that shows no
younger; women older than 25 years should have agglutination
screening if they report multiple partners in the B. Highest serum dilution that shows agglutination
prior 12 months C. Lowest serum dilution that shows agglutination
Routinely screen all women at 28-32 weeks in D. Lowest serum dilution that shows no
pregnancy, unless they had syphilis testing in the agglutination
prior 12 months The latex test for ASO includes latex
Routinely screen all women at delivery particles coated with streptolysin O. Serial dilutions
Routinely screen all women at first prenatal visit are prepared and the highest dilution showing
with repeat testing at 28-32 weeks and at delivery agglutination is the endpoint.
for women at high risk for acquiring syphilis  
Transmission of syphilis from the mother to the Interpret the following ASO results:Tube Nos.
fetus can occur at any point in the pregnancy and 1–4 (Todd unit 125): no hemolysis; Tube No.
any stage of the disease. The 2015 STD Treatment 5(Todd unit 166): hemolysis *
Guidelines recommend screening all pregnant A. Positive Todd unit 125
women with a serologic test for syphilis early in B. Positive Todd unit 166
pregnancy, or at the first prenatal visit. In addition, C. No antistreptolysin O present
women considered high risk for syphilis (increased D. Impossible to interpret
risk for acquiring syphilis or living in communities An ASO titer is expressed in Todd units as
with an increased prevalence of syphilis), should the last tube that neutralizes (no visible hemolysis)
also have serologic testing repeated at 28 weeks’ the streptolysin O (SLO). Most laboratories
gestation and again at delivery. consider an ASO titer significant if it is 166 Todd
units or higher. However, people with a recent
Any mother who has a fetal death after 20 weeks history of streptococcal infection may demonstrate
or a stillborn birth should undergo testing for an ASO titer of 166 or higher; demonstration of a
syphilis. For communities and populations in which rise in titer from acute to convalescent serum is
the prevalence of syphilis is high and for women at required to confirm a current streptococcal
high risk for infection (e.g. women with more than 1 infection. ASO is commonly measured using a
current partner, non-monogamous partners, rapid latex agglutination assay. These tests show
substance use or homelessness), serologic testing agglutination when the ASO concentration is 200
should also be performed twice during the third IU/mL or higher.
trimester: once at 28-32 weeks’ gestation and  
again at delivery. Which control shows the correct result for a
valid ASO test *
A. SLO control, no hemolysis
B. Red cell control, no hemolysis
MINI QUIZ: Ex. 6A & 6B C. Positive control, hemolysis in all tubes
D. Hemolysis in both SLO and red cell control
Diagnosis of group A streptococci The red cell control contains no SLO and
(Streptococcus pyogenes) infection is indicated should show no hemolysis. The SLO control
by the presence of * contains no serum and should show complete
A. Anti-protein A hemolysis. An ASO titer cannot be determined
B. Anti-DNaseB unless both the RBC and SLO controls
C. Anti-beta-toxin demonstrate the expected results.
D. C-reactive protein  
The serological diagnosis of group A A streptozyme test was performed, but the
streptococcal infection can be made by result was negative, even though the patient
demonstrating anti-DNase B. The antistreptolysin showed clinical signs of a streptococcal throat
O (ASO) assay can also be used; however, ASO infection.What should be done next? *
response is poor in skin infections. C-reactive A. Either ASO or anti-deoxyribonuclease B (anti-
protein is an acute-phase protein indicating DNase B) testing
inflammation. B. Another streptozyme test using diluted serum
  C. Antihyaluronidase testing
What is the endpoint for the antistreptolysin O D. Wait for 3–5 days and repeat the streptozyme
(ASO) latex agglutination assay? * test
 A streptozyme test is used for screening
and
contains several of the antigens associated with
streptococcal products. Because some patients
produce an antibody response to a limited number
of streptococcal products, no single test is
sufficiently sensitive to rule out infection. Clinical
sensitivity is increased by performing additional
tests
when initial results are negative. The streptozyme
test generally shows more false positives and false
negatives than ASO and anti-DNase. A positive
test
for antihyaluronidase occurs in a smaller number of
patients with recent streptococcal infections than
ASO and anti-DNase.
 
is a minimal hemolytic dose of SLO as that
amount of toxin that will completely hemolyse
0.5ml of the 0.5%suspension of rabbit red blood
cells. *
international units/IU
Todd units
HA units
anitbody titer
 
Properties of Streptolysin O (SLO): *
It is oxygen-labile unlike Streptolysin S (SLS)
It is antigenic; that is it elicits the production of an
antibody
It is haemolytically active in its reduced state
Its biologic activity is completely inhibited by low
concentrations (1.0µg/ml)
of cholesterol & certain related sterols
It is cardiotoxic
all of the above