Infectious Diseases, Microbiology and Virology A Q&A

Approach for Specialist Medical Trainees

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 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions 3

Q1.8 A 54-year-old male presents with fever, tachycardia and hypotension. A blood
culture is taken and becomes positive in 12 hours. The Gram stain is shown in
Figure 1.1.
Figure 1.1 Gram stain from a
positive blood culture. (A black
and white version of this figure
will appear in some formats. For
the colour version, please refer to
the plate section.)

Which of the components of the Gram stain is a fixative?

A. Safranin
B. Carbol fuchsin
C. Acetone
D. Crystal violet
E. Iodide

Q1.9 A 54-year-old male presents with fever, tachycardia and hypotension. A blood
culture is taken and becomes positive in 12 hours, and Escherichia coli is
identified. It is demonstrated to have in vitro resistance to many penicillins and
cephalosporins. Through what mechanism is an extended-spectrum beta-lactamase
gene most likely to be present in this E. coli?
A. Transduction
B. Transformation
C. Conjugation
D. Constitutively
E. De novo mutation

Q1.10 A 28-year-old male presents with diarrhoea. A non-lactose fermenting coliform

is isolated from faeces, and serological investigation of the isolate is performed.
The “O” antigen is positive, but the “H” antigen is negative. What is the most
likely explanation for this?
A. The isolate is non-motile
B. The isolate needs boiling prior to agglutination
C. The presence of a “Vi” antigen is masking the “H” antigen
D. The isolate is in a non-specific phase
E. The isolate is not a Salmonella species

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 4 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions

Q1.11 A 35-week pregnant female recalled a flu-like illness 2 days prior to delivery. She was
treated for peri-partum sepsis, and her new-born child was born in poor condition
and admitted to the neonatal intensive care department. Blood cultures (and subse-
quently cerebrospinal fluid) grew the organism depicted in Figure 1.2.

Figure 1.2 Gram stain of

cerebrospinal fluid. (A black and
white version of this figure will
appear in some formats. For the
colour version, please refer to the
plate section.)

Which laboratory test would be the most useful to confirm identification?

A. Coagulase
B. Catalase
C. Oxidase
D. Haemolysis on blood agar
E. Tumbling motility

Q1.12 A 34-year-old man presents with a fever, and an aerobic blood culture bottle grows
a Gram-negative rod. Which one of the following organisms is a strict aerobe?
A. Bacteroides fragilis
B. Kluyvera spp.
C. Proteus vulgaris
D. Prevotella melaninogenica
E. Pseudomonas aeruginosa

Q1.13 A 42-year-old patient presents with septic shock and is found to have a soft tissue
infection. Which component of the cell wall of Gram-positive bacteria may
contribute to the development of septic shock in Gram-positive infections?
A. Capsular protein
B. Endotoxin
C. Peptidoglycan
D. Phospholipid
E. Teichoic acid

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 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions 5

Q1.14 A 23-year-old female presents with a urinary tract infection. Which of the
following is true about urease producing bacteria?
A. Urease acidifies the urine rendering neutrophils inactive
B. Escherichia coli is urease positive
C. Acidifying the urine can lead to precipitation of struvite calculi
D. Morganella morganii is potentially a urea-splitting bacteria
E. Are commensal organisms that prevent hepatic encephalopathy

Q1.15 A 63-year-old female is diagnosed with urosepsis. She is profoundly hypotensive.

What is the most important endotoxin component leading to septic shock
from Gram-negative bacteria?
A. Lipopolysaccharide core oligosaccharides
B. Outer membrane vesicles
C. Lipid A
D. O antigens
E. Capsule

Q1.16 A 21-year-old female presents with necrotising fasciitis. Which of the following is
not a virulence factor of Staphylococcus aureus?
A. Lecthinase
B. Toxic shock syndrome toxin-1
C. Panton-Valentine leukocidin
D. Enterotoxin A
E. DNase

Q1.17 A 31-year-old male returns from Ethiopia and presents with a recurrent febrile illness.
What is the cause of the relapsing nature of fever in Borrelia recurrentis infection?
A. Antigenic drift
B. Antigenic shift
C. Rapidly developing antibody resistance
D. Antigenic variation
E. Encapsulation

Q1.18 A 16-year-old male presents with respiratory distress. Which organism produces a
toxin similar in action to that of Corynebacterium diphtheriae?
A. Bordetella pertussis
B. Pseudomonas aeruginosa
C. Serratia marcescens
D. Haemophilius influenzae
E. Clostridium tetani

Q1.19 An 18-year-old female presents with difficulty swallowing. A throat swab demon-
strates club-shaped organisms with differential staining. Corynebacterium diphther-
iae is suspected. What are Corynebacterium diphtheriae volutin granules made of?
A. Carbohydrate
B. Protein
C. Lipid
D. Phosphate
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 6 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions

Q1.20 A 45-year-old female presents with a heart block following a minor dog bite to the
palm of her hand (Figure 1.3).
Figure 1.3 Clinical appearance of the right
hand following a minor dog bite.

Corynebacterium ulcerans is isolated from the wound, and an Elek test is positive.
How does diphtheria toxin act?
A. ADP ribosylation of EF2
B. Ergosterol synthesis inhibition
C. Peptidoglycan disruption
D. Protein synthesis inhibition at the ribosome
E. Acetyl choline esterase inhibition

Q1.21 A 50-year-old male who underwent traumatic splenectomy two years ago
presents with tachypnoea, tachycardia and hypoxia. A mucoid Streptococcus
pneumoniae is subsequently grown (Figure 1.4).
Figure 1.4 Growth on blood agar
incubated in an aerobic environment
at 37°C for 24 hours. (A black and
white version of this figure will appear
in some formats. For the colour
version, please refer to the plate
section.)

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 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions 7

An avirulent, non-capsulate strain of pneumococcus can change to virulent

capsulate strains through which mechanism?
A. Plasmid transfer
B. Bacteriophage
C. Naked DNA transformation
D. Homogenous recombination
E. Slipped strand mispairing

Q1.22 A 56-year-old male is diagnosed with native valve endocarditis. A blood culture
grows a Gram-positive cocci on both blood agar and MacConkey agar, which is
ampicillin resistant. What is the likely identification of this organism?
A. Enterococcus faecalis
B. Enterococcus faecium
C. Streptococcus pneumoniae
D. Streptococcus bovis
E. Streptococcus anginosus

Q1.23 A 14-month-old child is admitted with a two-week history of coughing and is

admitted with severe paroxysms of coughing leading to hypoxia. Pertussis is
suspected. Which of the following is true about Bordetella pertussis?
A. Polymorphonuclear leucocytosis seen during infection
B. Can be clinically diagnosed initially within days of onset
C. Organism is isolated from the throat for several days following infection
D. Vaccine gives lifelong immunity
E. Tetracycline is effective in the paroxysmal stage

Q1.24 A 56-year-old female with urosepsis is not improving despite treatment with an
intravenous third-generation cephalosporin. Which bacteria are most likely to
harbour an extended-spectrum beta-lactamase gene?
A. Klebsiella pneumoniae
B. Enterobacter cloacae
C. Citrobacter freundii
D. Morganella morganii
E. Proteus mirabilis

Q1.25 A 49-year-old homeless patient attends the emergency department complaining

of itching and fever. He describes the onset of fever approximately 7 days ago. On
examination, he has a widespread rash and excoriation marks. What is the
most likely vector for this illness?
A. Aedes aegypti
B. Anopheles gambiae
C. Pediculus humanus humanus
D. Glossina spp.
E. Culex spp.

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 8 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions

Q1.26 A 54-year-old male presents with a flitting rash and an eosinophilia eight weeks
after return from the tropics. Which of the following infections require an
intermediate snail host?
A. Diphylobothriasis
B. Schistosomiasis
C. Echinococcosis
D. Paragonamiasis
E. Strongyloidiasis

Q1.27 A 31-year-old male presents with diarrhoea several days after return from
Nigeria. Entamoeba is seen on stool microscopy. Which of the following is
a non-pathogenic variant of Entamoeba histolytica?
A. Entamoeba dispar
B. Escherichia coli
C. Entamoeba hartmanni
D. Endolimax nana
E. Enterobacter cloacae

Q1.28 A 21-year-old female presents with a fever, adenopathy and a rash. Blood tests
demonstrate a lymphocytosis. Serological diagnosis of a primary viral infection
may be made by detection of which viral-specific immunoglobulin?
A. IgA
B. IgD
C. IgE
D. IgM
E. IgG

Q1.29 A 23-year-old male student has been recently admitted with invasive meningococcal
disease. He has made a good recovery but gives a history of a previous episode
of meningococcal septicaemia when he was 15 years old. There is no history of
other recurrent infections. Which immunodeficiency is most likely in this patient?
A. Adenosine deaminase deficiency
B. C7 deficiency
C. Job’s syndrome
D. Myeloperoxidase deficiency
E. Selective IgM deficiency

Q1.30 An 18-year-old male with chronic granulomatous disease (CGD) has recurrent
staphylococcal infection. What is the mechanism behind this?
A. Chemotaxis inhibition
B. Defect in phagocyte oxidase
C. Lack of C3d receptor
D. Failure of phago-lysosome fusion
E. IgM deficiency

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 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions 9

Q1.31 A 63-year-old female is diagnosed with urosepsis. She is profoundly hypotensive.

The lipopolysaccharide of Gram-negative bacteria is the principle ligand for
which specific toll-like receptor (TLR)?
A. TLR3
B. TLR4
C. TLR5
D. TLR7
E. TLR10

Q1.32 A 31-year-old male presents with acute hepatitis. He is found to have hepatitis C,
but subsequently clears this infection. Which pattern of cytokines is produced
by TH1 lymphocytes?
A. IL4 and IL10
B. TNF-β and IL1
C. IL2 and IFN-γ
D. IL1 and IL12
E. IL4, IL5, IL6 and IL13

Answers
A1.1 Answer B: An envelope
Viruses (Latin for toxin) contain DNA or RNA but not both. The central ribonucleic core
is surrounded by a protective shell (not a cell wall) of repeating protein units called
capsomeres. This has a symmetry which is either helical or icosahedral. Viral particles
contain polymerases and integrases but no true metabolic pathways. As completed virions
move from the host cell nucleus to the cytoplasm or from the cytoplasm to the
extracellular space, an external lipid-containing envelope may be added to the
nucleocapsid.

Further Reading
Abrescia NGA, Bamford DH, Grimes JM, Stuart DI. Structure unifies the viral universe. Ann Rev
Biochem. 2012;81:795–782.

A1.2 Answer E: Parvoviridae

There are several methods of classifying viruses, but perhaps the most widely used is
the Baltimore system developed in 1971, which designates viruses into one of seven
groups depending on the nature of the nucleic acid within the virus. Four aspects are
considered: (i) whether the nucleic acid is DNA or RNA, (ii) whether it is single
stranded or double stranded, (iii) whether it is positive or negative sense, and (iv) the
method of replication.

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 10 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions

Table 1 Classification of viruses.

I II III IV V VI VII
Double- Single- Double- Single- Single- Single- Double-
stranded stranded stranded stranded stranded stranded (+) stranded
DNA DNA RNA (+) RNA ( ) RNA reverse reverse
transcriptase transcriptase
RNA DNA
Adeno Parvo Reo Picorna Orthomyxo Retro Hepadna
Herpes Toga Paramyxo
Pox Flavi Rhabdo
Papilloma Corona Filo
Calici Arena
Hepe Bunya
Data from Baltimore (1971).

Further Reading
Baltimore D. Expression of animal virus genomes. Bacteriol Rev. 1971;35(3):235–241.

A1.3 Answer A: Single-stranded ( ) RNA

RSV is a single-stranded ( ) RNA virus of the family Paramyxoviridae. Infection with this
virus usually produces only mild symptoms, often indistinguishable from common cold
and minor illnesses. It is, however, also the most common cause of bronchiolitis and
pneumonia in children less than 1 year of age and can also cause croup. These syndromes
are more likely to occur in patients that are immunocompromised or infants born
prematurely. No antivirals are effective – the mainstay of therapy is oxygen. Palivizumab (a
monoclonal antibody against RSV surface fusion protein) can be given as monthly injections
begun just prior to the RSV season (usually for five months) as RSV prophylaxis for infants
that are premature or have either cardiac or lung disease.

Further Reading
Andabaka T, Nickerson JW, Rojas-Reyes MX, Rueda JD, Bacic Vrca V, Barsic B. Monoclonal antibody
for reducing the risk of respiratory syncytial virus infection in children. Cochrane Database Syst
Rev. 2013;4:CD006602.

A1.4 Answer D: Nipah virus

The paramyxoviridae (ss( )RNA) family includes viruses causing many common
infections. However, it has a complex taxonomy:
Subfamily Paramyxovirinae
Genus Henipavirus (Hendra virus and Nipah virus)
Genus Morbillivirus (Measles virus)

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 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions 11

Genus Respirovirus (Human parainfluenza viruses 1 and 3)

Genus Rubulavirus (Mumps virus and Human parainfluenza viruses 2 and 4)
Subfamily Pneumovirinae
Genus Pneumovirus (Human respiratory syncytial virus)
Genus Metapneumovirus (Human metapneumovirus)
Rubella virus is of the genus Rubivirus from the Togaviridae family (ss(+)RNA). Influenza
B virus is a genus of the Orthomyxoviridae family (ss( )RNA). Polio virus is of the genus
Enterovirus from the Picornaviridae family (ss(+)RNA). Parvovirus B19 is of the genus
Erythrovirus from the Parvoviridae family.

Further Reading
Virtue ER, Marsh GA, Wang LF. Paramyxoviruses infecting humans: the old, the new and the
unknown. Future Microbiol. 2009;4(5):537–554.

A1.5 Answer B: HPV-16 and HPV-18 are associated with genital cancers
HPV is a DNA virus from the papillomavirus family, of which there are numerous serotypes.
Serotypes 6 and 11 most frequently cause ano-genital warts, while serotypes 16 and 18 are
linked with ano-genital cancers. The E6 and E7 early viral proteins are considered
oncogenic, inhibiting tumour suppression genes: E6 inhibits p53, while E7 inhibits p53, p21
and RB. Diagnosis is through PCR on sample obtained during colposcopy.

Further Reading
Cutts FT, Franceschi S, Goldie S, Castellsague X, de Sanjose S, Garnett G, Edmunds WJ, Claeys P,
Goldenthal KL, Harper DM, Markowitz L. Human papillomavirus and HPV vaccines: a review.
Bull World Health Organ. 2007;85(9):719–726.

A1.6 Answer E: Erythrovirus

Humans can be infected by viruses from three genera from the Parvoviridae family, but no
members of the genus Parvovirus are currently known to infect humans. This creates a
confusion of terms because the human parvoviruses are not in genus Parvovirus. They are
from the genera: Dependoviruses (e.g. Adeno-Associated Virus), Erythroviruses (e.g.
Parvovirus B19) and Bocaviruses. In healthy individuals, the major presentation of B19
infection is erythema infectiosum, but in patients with underlying haematological disorders,
infection can lead to aplastic crisis. In immunosuppressed patients, persistent infection may
develop that presents as pure red cell aplasia and subsequent chronic anaemia. In utero
infection may result in hydrops fetalis, miscarriage or congenital anaemia.

Further Reading
Rogo LD, Mokhtari-Azad T, Kabir MH, Rezaei F. Human parvovirus B19: a review. Acta Virol.
2014;58(3):199–213.

A1.7 Answer D: Hepatitis C virus

Viruses typically have one of three natural histories; acute infection (e.g. influenza, hepatitis A,
Hanta, Nipah, hepatitis E), latent infection (e.g. herpes simplex, varicella zoster,
cytomegalovirus) or chronic infection (e.g. hepatitis B, hepatitis C, HIV).

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 12 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions

The global annual incidence of hepatitis C is estimated at four million, of whom 18–34%
will spontaneously clear the virus. Acute infection with hepatitis C is clinically mild and may
even be unrecognised or undiagnosed; acute resolution is not associated with any long-term
sequelae. The remainder of the patients are deemed to have chronic hepatitis C, which is
now the leading cause of end-stage liver diseases and liver-related deaths in much of the
world. Progression of liver fibrosis in chronic hepatitis C is extremely variable, and is
influenced by viral, host and environmental factors.

Further Reading
Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol. 2014;61(S1):S58–S68.

A1.8 Answer E: Iodide

Clinical samples requiring a Gram stain, such as sterile fluids and positive blood cultures, must
be heat fixed to a slide. A Gram stain can then be undertaken to determine the presence of
Gram-positive or Gram-negative bacteria and to enable morphological characterisation. The
slide should be flooded with crystal violet for 1 minute, which penetrates through cells and cell
membrane. This is then followed by addition of iodide for a further minute, which also enters
the cell wall and then binds with the crystal violet, forming larger molecules which are
insoluble in water and are therefore fixed in place. A decolouriser is then washed over the slide
for a few seconds, in the form of either acetone or alcohol, and the slide is then rinsed with
water. This dehydrates and therefore tightens the cell wall of Gram-positive organisms,
stopping the large crystal violate-iodine complexes from exiting the cells. Contemporaneously
the decolouriser degrades the outer membrane of Gram-negative organisms and the thin cell
wall cannot retain the crystal violet-iodine solution. A counterstain is then applied for
1 minute, usually safranin or carbol fuchsin, which cannot stain the dehydrated Gram-positive
organisms, but does adhere to Gram-negative organisms.
Gram-positive organisms have a single cell membrane, around which is a thick
peptidoglycan cell wall. Gram-negative organisms have a thin peptidoglycan cell wall, but
have two cell membranes, one on either side of the cell wall. Cell wall deficient bacteria
cannot be readily characterised by the Gram stain.

Further Reading
Public Health England. UK Standards for Microbiology Investigations TP39: Staining procedures.
2015. Available at: www.gov.uk/government/publications/smi-tp-39-staining-procedures

A1.9 Answer C: Conjugation

Bacteria can demonstrate resistance to antimicrobials through a number of mechanisms,
including target alteration, enzymatic destruction, porin loss and efflux pumps. The different
genes which dictate these cellular mechanisms can be constitutively present in some genera
and species of bacteria, or, more rarely may arise through de novo mutations in those
organisms which did not previously harbour them. More usually however, genetic material
encoding antimicrobial resistance mechanisms is transferred between organisms, either of
the same species, of different species in the same genera, or less frequently between genera.
This transfer of genetic material can occur through three main mechanisms: transduction,
transformation and conjugation (Figure 1.5).

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 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions 13

Figure 1.5 Transmission of genetic material between microorganisms.

In this case, Escherichia coli does not constitutively harbour an extended-spectrum beta-
lactamase (ESBL) gene in their chromosomal genetic material, and the development of a de
novo ESBL gene would be rare. Similarly, in the context of both this organism (E. coli) and
this family of resistance genes (ESBL), transduction and transformation is unlikely. Instead,
it is conjugation, and the transmission of plasmids with their additional genetic material,
which will bring to the host E. coli lineage the ability to produce ESBL proteins and confer
resistance to many penicillins and cephalosporins.

Further Reading
Holmes AH, Moore LSP, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin PJ, Piddock LJ.
Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387
(10014):176–187.

A1.10 Answer A: The isolate is non-motile

Salmonella species are non-lactose fermenting (with the exception of Salmonella Arizonae
and Salmonella Indiana) coliforms which produce hydrogen sulphide (with the exception of
some isolates of Salmonella Paratyphi A and Salmonella Typhi) when sub-cultured in the
presence of sulphur-containing amino acids (on agar plates such as xylose-lysine-
desoxycholate agar (XLD) or desoxycholate citrate (DCA)).
Two antigens are examined when identifying serovars of clinical Salmonella isolates;
somatic (oligosaccharide) “O” antigens and flagella “H” antigens. Variations in these antigens

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 14 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions

aid identification for clinical and epidemiological purposes; however, laboratory identification
can be complex. Salmonella isolates can exist in two “H” phases; phase I being motile and
phase II being non-motile (the latter as in this case). Isolates that are non-motile on primary
culture may be switched to a motile phase using a Cragie tube or the Jameson plate.
Somatic “O” antigens are heat stable and alcohol-resistant, but flagellar “H” antigens are
heat-labile. Some surface antigens in Salmonella may mask somatic antigens, meaning
bacteria will not agglutinate with somatic “O” antisera – one specific surface antigen is the
“Vi” antigen. The “Vi” antigen may only occur in three Salmonella serovars (out of over
2000): Typhi, Paratyphi C and Dublin, but is variably detected. Other non-lactose
fermenting coliforms can cause diarrhoea, including Shigella species, but as a rule these do
not produce hydrogen sulphide.

Further Reading
Public Health England. UK Standards for Microbiology Investigations B30: Investigation of faecal
specimens for enteric pathogens. 2014. Available at: https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_data/file/343955/B_30i8.1.pdf

A1.11 Answer E: Tumbling motility

Neonates are at a greater risk of sepsis and meningitis than other age groups due to
deficiencies in humoral and cellular immunity and in phagocytic function. Infants younger
than 32 weeks’ gestation receive little maternal immunoglobulin. Inefficiency in the
neonates’ alternative complement pathway compromises their defence against encapsulated
bacteria and poor migration and phagocytic function of neutrophils is apparent. Group
B Streptococcus is the most commonly identified organism, implicated in roughly 50% of
cases, with Escherichia coli accounting for a further 20%, meaning identification and
treatment of maternal genitourinary infections is an important prevention strategy. Listeria
monocytogenes is the third most common pathogen, causing 5–10% of cases. Patients
exposed to L. monocytogenes in pregnancy often describe a mild flu-like illness but the
organism exhibits transplacental transmission leading to sepsis in both mother and neonate.
Listeria is a catalase-positive, haemolytic Gram-positive rod that exhibits tumbling motility
at 25°C but not at 37°C. Tumbling motility is specific to Listeria and identified by the
hanging drop test. The cerebrospinal fluid response usually reflects the intracellular nature
of Listeria with a predominant mononuclear pleocytosis.

Further Reading
National Institute for Health and Care Excellence. Neonatal infection: antibiotics for prevention and
treatment NICE guidance. 2012. Available at: www.nice.org.uk/guidance/cg149

A1.12 Answer E: Pseudomonas aeruginosa

P. aeruginosa is an obligate aerobe. It is a Gram-negative, non-lactose fermenting organism
which is oxidase positive. It is a common commensal in wounds, but can become an
opportunistic pathogen.
Bacteroides spp. (Gram negative) and Clostridium spp. (Gram positive) are examples of
non-spore-forming and spore-forming strict anaerobes, respectively. Other obligate anaerobes
include Peptostreptococcus spp. and Veillonella spp. Bacteroides melaninogenicus has recently
been reclassified as Prevotella melaninogenica while Porphyromonas gingivalis (commonly

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 Chapter 1: Biology of Microorganisms & Host–Pathogen Interactions 15

found in the oral cavity) were originally classified in the Bacteroides genus. Kluyvera spp. has
been put forward as a new member of the Enterobacteriales and as such is only a facultative
anaerobe. P. aeruginosa is an obligate aerobe.

Further Reading
Moore LSP, Cunningham J, Donaldson H. A clinical approach to managing Pseudomonas aeruginosa
infections. Br J Hosp Med (Lond). 2016;77(4):C50C54.

A1.13 Answer E: Teichoic acid

The outside of a Gram-positive cell wall is covered with a thick layer consisting of
peptidoglycan (PGN) and lipoteichoic acid (LTA), which resembles Gram-negative
lipopolysaccharide (LPS). LTA and PGN are able to induce the release of nitric oxide, IL-1,
IL-6 and TNF-α by monocytes and macrophages and to activate the oxidative burst in vitro.
Furthermore, the effects of LTA and PGNs may be synergistic. Lipoteichoic acid can bind to
CD14 and to TLR – binding to TLR-2 has shown to induce NF-kB expression (a central
transcription factor), elevating expression of both pro- and anti-apoptotic genes. Its
activation also induces mitogen-activated protein kinases (MAPK) activation. LTA bound to
targets can interact with circulating antibodies and activate the complement cascade to
induce a passive immune kill phenomenon. It also triggers the release from neutrophils and
macrophages of reactive oxygen and nitrogen species and cytotoxic cytokines. Therefore,
LTA shares many pathogenic similarities with endotoxins.

Further Reading
Ginsburg I. Role of lipoteichoic acid in infection and inflammation. Lancet Infect Dis.
2002;2(3):171–179.

A1.14 Answer D: Morganella morganii is potentially a urea-splitting bacteria

Bacterial urease alkalinises urine, and urease-producing bacteria play a prominent role in the
formation of infection-induced urinary stones. Struvite stone formation occurs when
ammonia production increases and urine pH elevates to decrease the solubility of phosphate.
Proteus spp., M. morganii and Klebsiella pneumoniae are all potentially urea-splitting
bacteria, whereas while E. coli is the most common cause of lower urinary tract infections, it
is not associated with significant alkalinisation, nor is infection with Pseudomonas
aeruginosa. Hyperammonaemia can result from the production of excessive amounts of
ammonia due to bacterial urease, and its subsequent re-absorption into the systemic
circulation, which is implicated in hepatic encephalopathy.

Further Reading
Clericetti CM, Milani GP, Lava SAG, Bianchetti MG, Simonetti GD, Giannini O. Hyper-ammonaemia
associated with distal renal tubular acidosis or urinary tract infection: a systematic review. Pediatr
Nephrol. 2018;33(3):485–491.

A1.15 Answer C: Lipid A

Endotoxins are part of the outer membrane of the cell wall of Gram-negative bacteria.
Lipopolysaccharide (LPS) is a major component of the outer membrane, contributing
greatly to the structural integrity and protecting the membrane from chemical attack. LPS

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