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The cerebrospinal fluid sample is obtained by a physician usually via lumbar puncture in the L3-L4 region. The opening pressure is first measured (nl 90-180 mm of water in lateral position) and if it is elevated greater than 200 mm, no more than 2 ml of CSF should be withdrawn. Sterile technique is always used to reduce the risk of infection. Care must be taken to avoid injury to neural tissue.

Conditions in which glucose levels in the urine are above 100 mg/dL and detectable include:diabetes mellitus and other endocrine disordersimpaired tubular reabsorption due to advanced kidney diseasepregnancy - glycosuria developing in the 3rd trimester may be due to latent diabetes mellituscentral nervous system damagepancreatic diseasedisturbances of metabolism such as, burns, infection or fractures

A false positive result for blood on the reagent strip can occur when oxidizing contaminants, such as hypochlorite (bleach), remain in collection bottles after cleaning. Contamination of the urine with provodine-iodine, a strong oxidizing agent, used in surgical procedures can result in a false positive reaction. Microbial peroxide found in association with urinary tract infections may also cause false-positive results. Capoten® (Captopril) can cause decreased reactivity. The muscle tissue form of hemoglobin, myoglobin is a well-known cause of false-positive reactions on the blood portion of the reagent strip. When tissue hemoglobin is present, the urine specimen has a clear red appearance. Patients suffering from muscle-wasting disorders or muscular destruction due to trauma, prolonged coma, or convulsions or individuals engaging in extensive exertion may have myoglobin in their urine. Specific tests for myoglobin, such as immunodiffusion techniques or protein electrophoresis, are needed to confirm the presence of this substance in a urine specimen. Levels of ascorbic acid normally found in urine do not interfere with this test.

The nitrites portion of the reagent strip provides a rapid screening test for the presence of gram-negative bacteria that are often responsible for urinary tract infections. Although urine cultures are still needed to confirm the diagnosis and monitor any urinary tract or kidney infection, the need for a culture may not be obvious because in some cases of early bladder infection, the symptoms may be vague or the patient may be asymptomatic. Diagnosis and treatment of cystitis (bladder infection) is important because if left untreated it may result in kidney damage, impairment of renal function, hypertension and/or septicemia.

This test is sensitive to 0.06-0.1 mg/dL nitrite ion in urines with a low specific gravity and ascorbic acid concentrations of less than 25 mg/dL. Pink spots or pink edges should not be interpreted as a positive result because some medications can color urine red or turn red in an acid environment. Any degree of uniform pink color should be considered positive, suggesting the presence of 105 organisms/mL. Detection of low levels of nitrite ion may be enhanced by comparing the activated test strip to a white background. It is important to note that color development is NOT proportional to the number of bacteria present. The test is specific for nitrites and does not react with any other substances normally present in urine. Negative results do not necessarily rule out a urinary tract infection because yeasts or gram-positive bacteria unable to reduce nitrites may be the causative agent.

Using the esterase test in conjunction with pH, protein and nitrite provides a combination of tests which can screen for the presence of bacterial infection.

Most S. pneumoniae strains gain penicillin resistance by altering the penicillin-binding proteins in their cell wall.Penicillin molecules that cannot find a penicillin binding site cannot interfere with cell wall synthesis.Several different types of penicillin binding proteins may be involved, explaining the various levels of intermediate resistance that may be encountered with different strains of S. pneumoniae.Because different penicillin binding proteins may be involved, the level of penicillin resistance cannot be predicted by the oxacillin screening test.Infections caused by isolates of S. pneumoniae showing penicillin resistance in the intermediate range may be successfully treated by administering high doses of antibiotic.For this reason, the level of resistance with an accurate MIC test must be determined for all clinically significant isolates of S. pneumoniae.

Podschun R. Ullmann U.: Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenicity factors Clinical Microbiology Reviews. 11(4):589-603, 1998Bacteria belonging to the genus Klebsiella frequently cause human nosocomial infections. In particular, the medically most important Klebsiella species, Klebsiella pneumoniae, accounts for a significant proportion of hospital-acquired urinary tract infections, pneumonia, septicemias, and soft tissue infections.The principal pathogenic reservoirs for transmission of Klebsiella are the gastrointestinal tract and the hands of hospital personnel. Because of their ability to spread rapidly in the hospital environment, these bacteria tend to cause nosocomial outbreaks. Hospital outbreaks of multidrug-resistant Klebsiella spp., especially those in neonatal wards, are often caused by new types of strains, the so-called extended-spectrum-beta-lactamase (ESBL) producersThe incidence of ESBL-producing strains among clinical Klebsiella isolates has been steadily increasing over the past years. The resulting limitations on the therapeutic options demand new measures for the management of Klebsiella hospital infections.While the different typing methods are useful epidemiological tools for infection control, recent findings about Klebsiella virulence factors have provided new insights into the pathogenic strategies of these bacteria. Klebsiella pathogenicity factors such as capsules or lipopolysaccharides are presently considered to be promising candidates for vaccination efforts that may serve as immunological infection control measures.

Vancomycin and ampicillin resistance among Enterococcus species, particularly E. faecium have been on a steady increase.The disk diffusion screening test is used in many laboratories to detect vancomycin resistant strains. Note in the upper photograph that no zone of inhibition is seen around either the vancomycin or the ampicillin disk, indicating resistance to both drugs.Vancomycin-resistant Enterococci (VRE) have been divided into three phenotypes--Van A, Van B, and Van C.Vancomycin-resistant strains of E. faecalis and E. faecium are commonly of the Van A phenotype, demonstrating high level resistance (MIC's higher than 64 ug/mL), as illustrated by total resistance of the test strain in the E test and the VA disk, as illustrated in the lower photograph.The strain shown in the lower photograph, however, is ampicillin susceptible at the level of 1 ug/ml (see lower set of yellow arrows), indicating that this drug may be effective in treating the urinary tract infection.

Citron DM. Appelbaum PC.: How far should a clinical laboratory go in identifying anaerobic isolates, and who should pay? Clinical Infectious Diseases. 16 Suppl 4:S435-8, 1993Identification of anaerobic bacteria in specimens from sites of infection due to mixed organisms can be time-consuming and expensive. Laboratories should limit anaerobic workups by testing only those specimens that have been properly collected and transported to the laboratory.Use of selective and differential media for initial processing can provide rapid and relevant information to the clinician. Anaerobes isolated from normally sterile sites and sites of serious infection should always be completely identified. Group-or genus-level identifications may suffice in other instances.The Bacteroides fragilis group of organisms should always be identified because of their virulence and resistance to many antimicrobial agents.Some of the other organisms that warrant identification include Clostridium septicum (associated with gastrointestinal malignancy); Clostridium ramosum, Clostridium innocuum, and Clostridium clostridioforme (which are resistant to antibiotics); Clostridium perfringens (a cause of myonecrosis and gas gangrene,potentially serious infection); anaerobic cocci (which may be resistant to metronidazole and clindamycin); and fusobacteria (which may be virulent and resistant to clindamycin and penicillin).

Hershow RC. Khayr WF. Smith NL.: A comparison of clinical virulence of nosocomially acquired methicillin-resistant and methicillin-sensitive Staphylococcus aureus infections in a university hospital (University of Illinois at Chicago). Infection Control & Hospital Epidemiology. 13(10):587-93, 1992OBJECTIVES: To compare the clinical virulence of nosocomially acquired methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) infections in 1989.DESIGN: A retrospective comparison of host factors, in-hospital exposures, sites of infections, and outcomes of patients with nosocomial MRSA and MSSA infections. PARTICIPANTS: Forty-four adult patients with nosocomial S.aureus infections.RESULTS: The 22 MRSA-infected and 22 MSSA-infected persons were similar regarding mean age, gender, underlying diseases, and exposure to surgery. Before developing infection, MRSA-infected persons were more likely to have received antibiotics and to have stayed in the hospital > 2 weeks. Bacteremia was the most common presentation in the MRSA and MSSA groups (55% and 59%, respectively). Infectious complications and death were infrequent in both groups.CONCLUSIONS: MRSA and MSSA strains infect patients with similar demographic features and underlying diseases, but MRSA infections are significantly more common among patients with previous antibiotic therapy and a prolonged preinfection hospital stay. Clinical presentations and outcomes did not differ significantly between the 2 groups. Thus, similar to studies in the early 1980s, our findings do not suggest greater intrinsic virulence of MRSA.

Piscitelli SC., Shwed J., Schreckenberger P., Danziger LH. Streptococcus milleri group: renewed interest in an elusive pathogen. European Journal of Clinical Microbiology & Infectious Diseases.11:491-8, 1992The following review examines the bacteriological characteristics, epidemiology, pathogenicity and antimicrobial susceptibility of the "Streptococcus milleri group". "Streptococcus milleri group" is a term for a large group of streptococci which includes Streptococcus intermedius, Streptococcus constellatus and Streptococcus anginosus.Usually considered commensals, these organisms are often associated with various pyogenic infections including cardiac, intra-abdominal, subcutaneous and central nervous system infections, particularly with the formation of abscesses.Organisms of the "Streptococcus milleri group" are often unrecognized pathogens due to the lack of uniformity in classifications and difficulties in microbiological identification. Penicillin G, cephalosporins, clindamycin and vancomycin all possess activity against these streptococci.Use of agents with poor activity may promote infections with "Streptococcus milleri group" and allow it to exhibit its pathogenicity. An understanding of these organisms may aid in their recognition and proper treatment.

Cunningham MW.: Pathogenesis of group A streptococcal infections. Clinical Microbiology Reviews. 13):470-511, 2000Group A streptococci are model extracellular gram-positive pathogens responsible for pharyngitis, impetigo, rheumatic fever, and acute glomerulonephritis. A resurgence of invasive streptococcal diseases and rheumatic fever has appeared in outbreaks over the past 10 years, with a predominant M1 serotype as well as others identified with the outbreaks.Emm (M protein) gene sequencing has changed serotyping, and new virulence genes and new virulence regulatory networks have been defined. The emm gene superfamily has expanded to include antiphagocytic molecules and immunoglobulin-binding proteins with common structural features.At least nine superantigens have been characterized, all of which may contribute to toxic streptococcal syndrome. An emerging theme is the dichotomy between skin and throat strains in their epidemiology and genetic makeup. Eleven adhesions have been reported, and surface plasmin-binding proteins have been defined.The strong resistance of the group A streptococcus to phagocytosis is related to factor H and fibrinogen binding by M protein and to disarming complement component C5a by the C5a peptidase. Molecular mimicry appears to play a role in autoimmune mechanisms involved in rheumatic fever, while nephritis strain-associated proteins may lead to immune-mediated acute glomerulonephritis. Vaccine strategies have focused on recombinant M protein and C5a peptidase vaccines, and mucosal vaccine delivery systems are under investigation.

Low JC. Donachie W.: A review of Listeria monocytogenes and listeriosis. Veterinary Journal. 153:9-29, 1997Following the initial isolation and description in 1926, Listeria monocytogenes has been shown to be of world-wide prevalence and is associated with serious disease in a wide variety of animals, including man.Our knowledge of this bacterial pathogen and the various forms of listeriosis that it causes has until recently been extremely limited, but recent advances in taxonomy, isolation methods, bacterial typing, molecular biology and cell biology have extended our knowledge. It is an exquisitely adaptable environmental bacterium capable of existing both as an animal pathogen and plant saprophyte with a powerful array of regulated virulence factors.Most cases of listeriosis arise from the ingestion of contaminated food and in the UK the disease is particularly common in ruminants fed on silage.Although a number of forms of listeriosis are easily recognized, such as encephalitis, abortion and septicaemia, the epidemiological aspects and pathogenesis of infection in ruminants remain poorly understood. The invasion of peripheral nerve cells and rapid entry into the brain is postulated as a unique characteristic of its virulence, but relevant and practical disease models are still required to investigate this phenomenon.

Rouquette C. Berche P. The pathogenesis of infection by Listeria monocytogenes Microbiologia. 12:245-58, 1996 Listeria monocytogenes is a Gram-positive bacterium responsible for severe infections in human and a large variety of animal species. It is a facultative intracellular pathogen which invades macrophages and most tissue cells of infected hosts where it can proliferate. The molecular basis of this intracellular parasitism has been to a large extent elucidated. The virulence factors, including internalin, listeriolysin O, phospholipases and a bacterial surface protein, ActA, are encoded by chromosomal genes organized in operons. Following internalisation into host cells, the bacteria escape from the phagosomal compartment and enter the cytoplasm. They then spread from cell to cell by a process involving actin polymerisation. In infected hosts, the bacteria cross the intestinal wall at Peyer's patches to invade the mesenteric lymph nodes and the blood. The main target organ is the liver, where the bacteria multiply inside hepatocytes. Early recruitment of polymorphonuclear cells lead to hepatocyte lysis, and thereby bacterial release This causes prolonged septicaemia, particularly in immunocompromised hosts, thus exposing the placenta and brain to infection. The prognosis of listeriosis depends on the severity of meningoencephalitis, due to the elective location of foci of infection in the brain stem (rhombencephalitis). Despite bactericidal antibiotic therapy, the overall mortality is still high (25 to 30%).

Newfield RS. Vargas I. Huma Z.: Eikenella corrodens infections. Case report in two adolescent females with IDDM. Diabetes Care. 19:1011-3, 1996OBJECTIVE: To alert physicians caring for patients with diabetes to the microorganism Eikenella corrodens and to discuss the appropriate preventive and therapeutic measures to take against this potentially morbid opportunistic Gram-negative bacilli.CASES: We present two cases of extra-oral E. corrodens infections in adolescent females with IDDM. The first patient had diabetes of 4 years' duration, which was moderately well controlled. Chronic finger biting resulted in a complex felon that evolved gradually and worsened while the patient received cephalexin orally. Delay in seeking further intervention resulted in necrosis of her distal fingertip and nail bed. The second patient had poorly controlled diabetes for 5 years. She developed an acute thigh abscess at an insulin injection site that resolved after drainage and intravenous antibiotics.CONCLUSIONS: E. corrodens commonly inhabits the human oral cavity and becomes a pathogen mostly when host defenses are impaired, causing abscesses and infections that are at times fatal. Patients with IDDM are compromised hosts and with daily microtrauma to their skin via glucose monitoring and insulin injections, are prone to develop E. corrodens infections that can be introduced through oral secretions by licking or biting their skin. Educational efforts aimed at preventing exposure of traumatized skin to oral secretions can minimize the risk of E. corrodens infections in compromised hosts.Early intravenous administration of antibiotics, bearing in mind E. corrodens resistance to clindamycin, metronidazole, and other antibiotics, coupled with prompt surgical intervention, is essential in successfully managing E. corrodens infections.

Disseminated Intravascular Coagulation (DIC) is best described as a disorder of consumption, because clotting factors are depleted from the blood. Basically, clotting occurs randomly throughout the body, as opposed to just in the localized areas where vascular damage has occurred, consuming clotting factors and other components such as platelets in the process. Symptoms may range from a mild bleed, to severe, profuse bleeding, primarily dependant upon the availability of clotting factors. As more and more coagulation factors and components are consumed, the disorder progresses and symptoms worsen. Most heavily impacted are the levels of factors I, V, and VIII as well as the number of available platelets. Clinically, DIC is detected via an elevated (positive) FDP, positive D-dimer test, a prolonged PT and APTT, plus the manifestation of hemorrhagic episodes. DIC is diagnosed as two primary types, acute and chronic. Acute DIC manifests in a few hours or a few days, has a high mortality rate, and is seen in infections, obstetric complications, liver disease, and tissue injury. Chronic DIC is a secondary condition to some other disease state. Once you treat the primary disease, this type of DIC will go away. Treatment is often factor replacement therapy through the use of fresh frozen plasma and/or cryoprecipitate.

Acquired Immunodeficiency syndrome (AIDS) is caused by the Human Immunodeficiency virus (HIV). When HIV enters a person's bloodstream, it attacks and kills the T-helper lymphocytes, which are essential to the body in fighting off infections. As these cells are lost, so is the body's ability to fight infection. Possibly months after the initial infecting episode, an infected person develops a mononucleosis-like illness lasting a week or two. A person may then be free of symptoms for years. But as the T-helper cells die, the person becomes vulnerable to many serious infections. The expected mortality is 100%, and there is no vaccine available to develop specific immunity.

Postexposure prophylaxis will be determined by exposure type and HIV infection status of source person. The postexposure prophylaxis determined by a qualified practitioner will balance risk of infection with toxicity of the medications.The postexposure prophylaxis must be started hours after the exposure.The postexposure prophylaxis should be re-evaluated 72 hours after exposure, particularly if additional information is available about source person.The postexposure prophylaxis may be necessary for 6 months.

The Florida Legislature finds that the public health will be served by facilitating informed, voluntary, and confidential use of tests designed to detect HIV infection.

At this time an enzyme called protease, using enzymes and proteins from preliminary protein molecules, forms capsomere segments which unite to form an icosahedral capsid.The capsid then changes into a bullet-shaped capsid and surrounds the viral RNA.Next some of the host cell's membrane joins with the viral glycoproteins gp120 and gp41 to form the spikes.Last, part of the host cell's surface membrane encloses the virus and becomes the envelope.

After penetration of the cell membrane by the gp41, the HIV capsid enters the cell's cytoplasm. Next, cellular enzymes strip away the capsid so that the HIV genome is released. Also stripped away are proteins p24 and p17. Protein 24 coats the HIV genome and protein 17 lines the inside of the capsid.

The DNA provirus continues to encode new HIV particles within the host cell. During this early stage the injured host cells, such as T-lymphocytes, are able to replace themselves, and the body remains able to launch a defensive response. Eventually, though, the number of viruses becomes overwhelming.

Most likely means of dissemination: Solid or aerosolPrimary route of entry: Inhalation, absorption, or ingestionGeneral signs and symptoms: Sudden fever, chills, headaches, muscle aches, joint pain, dry cough, progressive weakness, and pneumonia.The disease is not transmissible through human contact.  When used as a WMD, infection would be acquired by handling infected material, eating or drinking contaminated food or water or by breathing in the bacterium.

Biological attacks involve bacteria, viruses or natural toxins. The effects of toxins can be immediate but for bacteria and viruses the effects may not be apparent for weeks. A bio-terrorist may attack by infecting animals, contaminating food and water, spraying bacteria or viruses into the air. In infections such as smallpox and plague, once a few individuals are infected they can further spread the disease from person to person. An attack could also come from through a building’s ventilation system, the mail, or even through exposure to an infected terrorist seeking to spread disease during an infectious stage.

Markely increased stainable iron is present in this biopsy. Iron stores may be increased in sideroblastic anemia, chronic infections, hemochromatosis, hemosiderosis due to numerous blood transfusions, chronic hepatitis, cirrhosis, and uremia.

Another rare but abnormal type of plasma cell is the Mott cell (morula cell). The compartments visible in the cytoplasm are immunoglobulins which have not been released. Mott cells may be seen in parasitic infections and malignant tumors.

Specialists in immunohematology perform all testing prior to blood transfusions and work to prevent transfusion infections. They also investigate any post-transfusion reactions. This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in clinical chemistry analyze body fluids such as blood, urine, and spinal fluid to determine the chemical makeup, including the amount of carbohydrates, proteins, enzymes, and trace elements. The special covers urine microscopics and chemical evaluation of the liver, kidneys, lungs, heart, and other vital organ systems. This specialty also covers all testing performed in the specialties of radioassay and blood gas analysis. Specialists in blood banking can perform all immunohematology testing as well as testing from the specialties of clinical chemistry, hematology and serology/immunology that relates to donor blood. Specialists in immunohematology, clinical chemistry, hematology, and serology / immunology may perform all tests in the blood banking specialty.

Neutrophils have a relatively short life span.They are produced in the bone marrow, and when they reach the band or segmented stages are released into the peripheral blood.They remain there for approximately ten hours before randomly entering body tissues.Neutrophils in the blood stream can be divided into circulating granulocyte pool(CGP) and marginating granulocytic pool (MGP).The white blood cell count reflects the cells in the circulating pool.The cells in the marginating pool move quickly into the circulating pool when needed.During an infection the neutrophil concentration of the peripheral blood can increase almost immediately due to the shift of these cells from the marginating pool and release from the bone marrow storage pool, if needed.Neutrophils then migrate to areas of tissue damage or infection.Neutrophils do not reenter the blood stream from the tissues, thus end their life in the tissues either as a result of phagocytosis or senescence.

This program will provide you with basic information about bloodborne pathogens and vital precautions you must take to minimize your risk of workplace exposure to these infections.

Patients with Hepatitis B and other bloodborne infections can appear healthy, so you can't tell whose blood is infectious.So treat all:blood, body fluids, secretions (except sweat), excretions, non-intact skin, and mucous membranes as if they were infectious.That's what the term Standard Precautions means.

HIV is caused by the Human Immunodeficiency virus.When HIV enters a person's bloodstream, it attacks and kills the T-helper cells. These cells are part of a group of white blood cells known as lymphocytes, which are essential to the body in fighting off infections.As these cells are lost, so is the body's ability to fight infection.

The Hepatitis B Vaccine is one of the most important ways to prevent infection. About 90% of people who receive it get immunity.The present recombinant vaccine is made by genetically altered bakers yeast and contains no blood components. It is very safe.Side effects are minimal. Symptoms such as temporary soreness at the injection site, mild fever, or joint pain may occur but are rare.The procedure consists of three shots in the upper arm given over a six month period.The OSHA standard requires that employers provide the vaccine free of charge to you if your occupation puts you at risk. You may decline the vaccine; but you will be asked to sign a Declination Statement.

Infection is obviously a very serious indication, and effective antibiotic levels must be achieved as soon as possible. However, many antibiotics also have nephrotoxic or ototoxic effects; the concentrations of these antibiotics need to be monitored. Examples of antibiotics that are monitored by TDM include: Amikacin Gentamicin Tobramycin VancomycinAntibiotics such as ampicillin that are readily cleared and have a wide therapeutic window are not usually monitored by TDM.

At John’s particular hospital, a stop sign on the door means not only means respiratory isolation, but also that special precautions for tuberculosis are in effect. At this point, John should obtain a a special particulate respirator mask which will be available outside the patient's room. He should put on the mask before entering the room, wash his hands before and after contact with the patient, and wear gloves and appropriate protective clothing during all contact with the patient. TB and most respiratory infections are transmitted via droplets in the air from respiratory secretions – thus the need for the masks.

Microlances (such as the Tenderfoot™ (ITC) or the QuikHeel™ (BD), shown here, are used to puncture the heel & collect capillary blood.These devices control the depth of incision, since going too deep into an infant’s heel could injure the heel bone, and cause osteomyelitis (bone infection).

The most important bloodborne pathogens are: Hepatitis B and C & Human Immunodeficiency Virus (HIV). Hepatitis B is very infectious via the blood-borne route. 30% of needle-sticks from patients who are Hepatitis B will result in infection. Hepatitis C is much more common in the United States. HIV is rarely transmitted via needle-stick injury. Nevertheless, utmost care is needed, because of its very serious nature. HIV is not transmitted by casual contact.

Epithelial cells in large numbers within sputum smears means that the specimen is predominantly oral saliva, rather than true sputum from the lung. Epithelial cells in urine smears indicate that the sample has been contaminated by organisms found on the vulva or distal urethra. Bacteria found near or on epithelial cells are usually normal contaminating bacterial flora.White blood cells indicate inflammation and possible infection. The direct smear examination should focus within and around these cells.Red blood cells in a direct smear are not usually significant.Yeast may be present as normal flora in upper respiratory tract or genital tract. They may be significant if they predominate, or if budding yeast forms are seen.Hyphae are more likely to indicate the presence of fungal infection, but this determination requires correlation with clinical findings.Bacteria found in spinal fluid, blood, tissue and specimens from other sterile sites are always significant.Body fluids which are normally sterile must be examined carefully. If only one organism per oil immersion field is identified, then there are about 105 organisms per mL present in the sample! Bacteria observed in specimens from the throat, genital tract and other areas containing normal flora suggest infection only if their composition and type varies significantly from the norm.

Semen analysis can provide important information related to the function of the male reproductive system but, even when results are within normal limits, it does not ensure that a male is fertile. A normal semen analysis result does not mean that all causes of male infertility have been ruled out. One reason for this is that there can be considerable differences between one semen analysis result and another in a single individual. On the other hand, an abnormal result does not always mean that a couple cannot conceive a pregnancy. Men with suboptimal sperm counts have been known to father children. Also, infection, trauma, stress, febrile illness and medications can cause temporary subfertility. For all of these reasons multiple specimens are recommended for a complete analysis of the semen.

Large clumps of white cells, such as the ones shown in the slide, are typically found in chronic infection. The clumping is due to increased mucus in the urine.

Parasites which may be found in urinary sediments include Trichomonas vaginalis, Enterobius vermicularis and Schistosoma haematobium. It is also important to note that parasites and parasitic ova may be seen in urine sediments as a result of fecal or vaginal contamination. This slide shows examples of Trichomonas vaginalis. In the female, Trichomonas is usually found as a contaminant from vaginal infection and is often accompanied by an increase in the number of white cells. Trichomonas is highly motile, measuring 5 - 15 microns with a characteristic pear shape. It has multiple anterior flagella and the nucleus is often apparent.

The natural history of TB infection is usually followed by an immune response and latency after exposure. In about 5-10% of cases, the latent period progresses to an active infection.The organism that causes TB infection is Mycobacterium tuberculosis. This organism is pictured in the photograph to the right as observed when stained with acridine orange stain. Infection occurs when a susceptible person inhales droplet nuclei containing Mycobacterium tuberculosis and the organism reaches the alveoli of the lungs.About 2-12 weeks after infection, the immune system limits multiplication of additional bacteria and the immunological test becomes positive.Latent tuberculosis infection (LTBI) is the stage when the viable organism remains in the body, and the patient has no symptoms and is non-infectious.Most infected persons do not experience clinical illness and are noninfectious. About 5-10% of persons infected with Mycobacterium tuberculosis who are not treated will develop TB during their lifetime. The risk for progression is highest during the first several years after infection.TB infects the lungs most often; however, it can infect almost any organ in the body, including bones and joints.

The following persons are at higher risk for exposure to and infection from Mycobacterium tuberculosis: Frequent travelers to tuberculosis endemic areas; Residents and employees of high-risk congregate settings such as correctional facilities, long-term care facilities, and homeless shelters; Healthcare workers who serve high-risk patients or have unprotected exposure; Medically underserved and low-income populations; Infants, children, and adolescents exposed to adults in high-risk categories.

The TST interpretation depends on the measured diameter of the induration and the clinical status of the patient.An induration of 15 or more millimeters is considered positive in all persons.An induration of 10 or more millimeters is considered positive in patients in the high risk progression groups and in mycobacteriology laboratory workers.An induration of 5 or more millimeters is considered positive in the high risk infection groups.

A false negative reaction is no induration after a TST even if the person is infected with Mycobacterium tuberculosis. Some causes of this are: weakened immune system,recent, old or overwhelming TB infection,immature immune system (<6 months of age),some viral illnesses,recent live-virus vaccinations,incorrect TST administration or interpretation.

If an initial skin test is classified as negative, a second skin test should be administered 1-3 weeks after the first result was read.If the second test is positive, it probably represents a boosted reaction, from a past infection. Response to tuberculin decreases over time. The initial TST stimulates the immune system, so that there is an immune response to a subsequent TST.If the second test is negative, the person is classified as not infected.Two step testing eliminates the false negative test results due to a weakened immune system.

Patients with active TB should be assigned to single-patient rooms in which entry of HCWs and visitors is controlled.All HCWs use a N95 disposable respirator.Visitors may be offered respiratory protection and should be instructed by HCWs on the use of the respirator before entering.The room has requirements for controlled ventilation, negative pressure, and air filtration.Each isolation room should have a private bathroom.

There are a number of conditions in which hypersegmented neutrophils may be seen, such as megaloblastic anemias that include folic acid deficiency and pernicious anemia. Individuals who are receiving chemotherapy or have long-term chronic infections may also have hypersegmented neutrophils.The cells seen in these conditions would be classified as pathological since the body is responding abnormally as a result of either a deficiency of a component needed for DNA production or because of the toxic effect that chemotherapy drugs have on DNA.

The presence of hyposegmented neutrophils can be an acquired phenomenon, as a result of severe infection, burns, malignancy, chemotherapy or other drugs such as sulfonamides. When the causative agent has been removed, the cells will return to normal. Percentages of neutrophils affected will vary in this condition. Hyposegmented neutrophils as an aquired phenomenon are known as pseudo-Pelger-Huet cells. These are considered pathological.

Dohle bodies are frequently seen in conditions such as infection or burns when toxic granulation is also present. The cell in this slide has two Dohle bodies as well as toxic granulation. Vacuoles, although not present in this cell, can frequently appear in a cell containing toxic granulation and Dohle bodies.

Dohle bodies are seen in a number of conditions, including infections, burns, measles, leukemia and chemotherapy. Dohle bodies are classified as pathological in the sense that they are only present when the body is responding to an unusually severe stress or stimulus. This severe stress may cause the cytoplasm of some cells to mature improperly. Their presence does not aid in the diagnosis of the disorders in which they are found, but they are frequently seen along with toxic granulation and/or vacuoles often present in infections and burns. Recognition is important because their appearance is similar to May-Hegglin bodies, which appear in a rare hereditary disorder called May-Hegglin anomaly.

Illustrated in the photograph is a normal bone marrow smear stained with Wright/Giemsa stain. Note the evenly distributed cells with normal maturation in both the myeloid and erythroid maturation sequences.An estimation of the percentage composition of cells can be made by experienced observers from scanning of multiple fields. In some instances a detailed differential count of 300 or more cells must be made.In normal bone marrows, the myeloid to erythroid ratio (M:E ratio)ranges from 1.2:1 to 5:1.A ratio of less than 1.2:1 indicates depressed leukopoiesis or erythroid hyperplasia. Ratios of 6:1 or greater usually indicates infection, erythroid hypoplasia, or chronic myelogenous leukemia.An assessment of the overall cellularity is also useful. In general, cellularity of less than 25% indicates hypoplasia; greater than 75% indicates hyperplasia.

The following pages in this presentation includes a series of white blood cell abnormalities that may be identified in a peripheral blood smear. Many of the cases will simulate the practice of a peripheral smear review by a hematology morphologist. He/she must asses what responses in patient care may be triggered by the clinician attempting to interpret the reported findings on a peripheral smearObservations of white blood cell abnormalities in the peripheral blood smear should be reported so as to direct the physician to an immediate specific diagnosis, such as: (1) atypical lymphocytes suggesting infectious mononucleosis rather than leukemia, (2) toxic granules in neutrophils as in acute infections, or atypical granules suggesting a genetic disorder, (3) an unusual mix of cells, such as too many or too few neutrophils, monocytes, or other myeloid cells, and (4) the presence of giant platelets, myelocytes, or other cells suggesting a myelodysplastic syndrome.In summary, laboratory data should be presented to clinicians in a user friendly way to promote effective decision making. The design of the data base of information must be directed toward providing clinically helpful information clearly and quickly in order to facilitate appropriate action in terms of optimizing patient care outcomes.d

In 1952 Chediak (a Cuban physician) reported a childhood disorder in which abnormal cytoplasmic inclusions appeared in the neutrophils of four family members. In 1954 Higashi reported a similar abnormality in an 11-month old Japanese infant. These inclusions were identified as lysosomal in origin and found in this rare autosomal recessive disorder Death was usually related to recurrent infections or hemmorhage though now some of the affected patients live to reproduce. Ocular and cutaneous albinism, increased susceptibility to pyogenic infections, abnormal granules in neutrophils, and a bleeding tendency are prominent findings. The striking neutrophilic inclusions appear as coarse intra-cytoplasmic azurophilic granules (see photograph).These granules arise from dilated portions of the Golgi-endoplasmic reticulum lysosomal apparatus. Aleutian mink and other animals are known to have Chediak-Higashi syndrome. Azurine pelts from infected mink were once prized by coat makers.

As mentioned on the previous page, high percentages of eosinophils may be present in the peripheral blood smears of patients with a variety of conditions--asthma, urticaria, Loeffler's syndrome, larval parasitic infections and in chronic eosinophilic leukemia. One exception to the association of eosinophilia with parasitic infections is a fatal case of disseminated strongyloidiasis reported many years ago by Miale (Hematology--5th Edition, Mosby, pg. 776, 1977) in which the peripheral blood eosinophilia was masked by the administration of corticosteroids.

The cytoplasm of eosinophils is evenly filled by numerous orange-red granules of uniform size. They do not overlie the nucleus.The eosinophil granules contain numerous enzymes including peroxidase, phospholipase D, catalase, acid phosphatase, and vitamin B12-binding proteins.Their ability to kill bacteria is less than that of neutrophils. Their main purpose is to counteract parasitic infections and to participate in immune allergic reactions.They may also be increased in a variety of nonimmunologic inflammatory responses from bacteria and fungi causing chronic infections. Malignancies, collagen vascular diseases, and myeloproliferative disorders may also may be settings for prominent eosinophils.

A 14 year-old boy came to the physician's office with a sore throat that progressively worsened over a three day period. His posterior pharynx was swollen ,shiney and erythematous. The boy complained of pain on swallowing. His temperature was 98.5F. A rapid direct streptococcal antigen test was positive. However, his symptoms did not subside over the next two days while on antibiotic therapy. Anorexia and nausea were persistent and compounded by a frontal headache. Cervical lymph nodes became noticeably enlarged. The results of the CBC were: WBC 11.9/mm3 with 17% segmented neutrophils, 5% bands, 72%(60% atypical--see photograph)lymphocytes and 6%monocytes. All red cell findings were normal. A monospot test was positive. This is a case of group-A streptococcal infection superimposed on infectious mononucleosis. Symptoms subsided in 3 weeks following completion of the antibiotic therapy.

An 80 year old man was seen in the emergency room with sudden onset of right sided chest pain accentuated on inspiration. His cough was productive of yellow sputum, and he was short of breath.His temperature was 101.2F. A chest X-ray revealed right middle lobe pneumonia. His hemoglobin was 15.2 gm/dl, HCT 44%, and RBC 4.5 m/ml. The white blood count was 35,000/cuml, with 45% neutrophils, 20% bands, 5% lymphocytes, 3% eosinophils, 2% basophils, and 25% atypical monocytes as noted in the photograph.The atypical monocytes had abundant blue-grey cytoplasm with a few scattered vacuoles, which, in company with toxic neutrophils appeared to be a response to infection.The patient had a past history of tuberculosis which may account for the monocytosis.