LABORATORY DIAGNOSTICS OF INFECTIOUS DISEASES

(2 lessons)

Laboratory examinations:

1) standard routine testing, usual screening

2) organ specific tests indicated on the basis of symptoms
3) inner milieu describing tests
4) type and intensity of inflammation detecting tests
5) etiology detecting tests

Ad 1) common and simple tests, e.g. ESR, blood count, urinalysis, in older persons ECG

Ad 2) tests described in internal propedeutics, examples:

cough lungs examination chest X-ray
icterus (jaundice) liver examination serum liver enzymes and bilirubin, urine
bilirubin and urobilinogen, liver and biliary tact
USG
etc.

Ad 3) tests used in various medical specialties, will be later discussed in intensive care
It is not true that inner milieu testing = blood gases and acid-base balance (Astrup).Blood gases
and acid-base tests belong to extended spectrum of tests:

Situation Testing appropriate

general alteration; routine:
preexisting organ disease blood count
glycaemia, serum ions (Na, K, Cl)
serum urea, creatinine
urinalysis
serum AST, ALT
dyspnea, disturbed pulmonary extended:
function; peripheral blood oxygen saturation (pulse oxymeter)
hypotension, cardiovascular pH and blood gas tests (Astrup)
failure; coagulation tests
hemorhagic signs; serum albumin
multiple organ failure

Ad 4) hematological, biochemical and pathological testing detecting type of infection

- blood count and differential count of leukocytes
- pyogenic, suppurative infections: leukocytosis, left shift (immature neutrophilic
polymorphonuclears bands, possibly metamyelocytes), cytoplasmic granulation of
neutrophils, absence of eosinophils
- intracelular pathogens: decreased number of PMNs, increased lymphocytes and
monocytes
- increased eosinophils: allergy, tissue helmintoses
- CRP and other acute phase proteins
- erythrocyte sedimentation rate (ESR)
 Dynamics of inflammatory parameters in the course of bacterial infection.

Ad 5) microbiology diagnostics and clinical interpretation

a) Direct methods of pathogen identification

- microscopy: light, electron, ...
- culture: aerobic vs. anaerobic, on selective media, ...
- antigen detection: clearview, latexagglutination, ....
- molecular genetic methods: PCR, genetic probes, ...

Method Contribution Advantages Disadvantages

microscopy morphology and quick, easy, inappropriate in processing of
number of microbes in cheap; low high quantity of samples;
sample; demands on good experience needed;
microbes-leukocytes equipment only some microorganisms can
and microbes with each be detected on the basis of
other interrelationship morphology
culture features of isolated easy, cheap; risk of selective identification
agents; low of only some microbes;
complete identification; demands on danger of laboratory infection;
sensitivity testing; equipment prolonged testing some
storage for future pathogens grow slowly
testing
antigen detection detects presence of the easy, cheap, low sensitivity; with some
searched agent quick; low samples also low specificity
demands on
equipment
specific genome detects presence of the quick; high expensive;
detection searched agent sensitivity expensive equipment needed;
easy contamination

b) Indirect methods of pathogen identification

- serology: agglutination, hemagglutination, hemagglutination inhibition,
complementfixation, enzyme-linked immunosorbent assay (ELISA), Western blot
etc.
- skin tests: tuberculin test (PPD test, Mantoux II)
- detection of lymphocyte sensibilisation (TB diagnostics)

Method Contribution Advantages Disadvantages

specific detects easy, cheap; inappropriate for identification
antibodies antibody appropriate for of agents with high antigenic
detection response routine processing variability
skin tests detects specific easy, very cheap low reliability; risk of allergic
cell-mediated reaction; may induce patient
immunity immunisation not possible to
repeat
specific cell- detects specific more precise, no risk much more expensive than
mediated cell-mediated of allergy or patient skin test
immunity immunity immunisation
detection

Serological tests interpretation:

acute infection: single sample testing (IgM vs. IgG)

paired sera testing (fourfold elevation of specific antibody titres)
chronic infection: dynamics of antibody titres in time
antibodies avidity testing (the strength of Ab-Ag bind)

Indirect detection methods are based on the detection of specific immune response to infection:

general advantages: can differentiate infection and colonisation

can detect infection that already passed
general limitations: cannot be used in acute and quickly progressing infections (specific immunity
occurs after 1-3 weeks)
not reliable in local infections (e.g. on mucosal surface only)
fail in immunocompromised persons
UPPER RESPIRATORY TRACT INFECTIONS
(1 lesson)

Introduction, pathophysiology
- antiinfective defense of the respiratory tract
- respiratory tract as a continuum, involvement of its parts ranging from nose to trachea
- closely related structures (conjunctiva, paranasal sinuses, middle ear)
- inflammatory edema of respiratory tract mucosa and submucosal lymphatic tissue

Etiology:
- physiological bacterial colonization of the upper respiratory tract
- respiratory viruses: rhinoviruses, coronaviruses, influenza and parainfluenzaviruses, RSV
- pathogenic bacteria:
nasal mucosa: Staphylococcus aureus
nasopharynx: Streptococcus pyogenes, corynebacteria, anaerobes
epiglottis and below: H. influenzae and other gramnegative nacteria
sinuses (sinusitis, otitis): various agents viruses, bacteria, fungi

Syndromes and etiology:

- acute rhinitis, coryza, common cold: viruses
- acute pharyngitis and tonsillitis: viruses, bacteria
- acute laryngitis: viruses
- acute epiglottitis: H.influenzae
- acute tracheitis: viruses

Complications:
- sinusitis
- otitis media, mastoiditis
- peritonsillar abscess

Separatelly discussed diaseases:

- influenza
- infectious mononucleosis
- diphtheria

Diagnostics, differentiation of viral and bacterial disease:

- inflammatory parameters
- tests for etiology detection - bacterial infection, viral infection
- complementary and syndrome-specific tests
URINARY TRACT INFECTIONS
(1 lesson)

Pathogenesis of urinary tract infections

- route of infection: ascending infection,
hematogenous infection
per continuitatem very rare
- predisposing factors:
- anatomical factors (short uretra in females, congenital defects...)
- mechanical obstruction from inside (lithiasis, tumours, scarring and postoperative strictures)
and from outside (prostatic hypertrophy, tumours, pregnancy)
- functional neuromuscular defects (paraplegia, sclerosis multiplex, spina bifida)
- metabolic factors (diabetes mellitus)
- microbial pathogenic factors:
- adherence to uroepithelium, colonisation (hemolytic E.coli)
- biofilm production (catheters, chronic infection)
- tissue invasion

Classification of UTI with regard to etiology and pathogenesis:

- community-acquired UTI
- cystitis, pyelonephritis E.coli, Proteus mirabilis
- urethritis, prostatitis Mycoplasma, Chlamydia, Neisseria gonorhoae
- chronic UTI in diabetic patients
- besides Gramnegative bacilli frequently Enterococcus
- hospital-acquired UTI
- commonly associated with permanent catheterisation or endoscopy (cystoscopy)
- etiology: multiresistant Gramnegative bacilli (Pseudomonas, Enterobacter, Klebsiella)

Examination procedure
- physical examination
- laboratory testing:
- inflammatory parameters (blood count + differential count of leukocytes, CRP)
- biochemical testing of urine, urine culture
- blood culture if pyelonephritis suspected
- renal function testing (urea, creatinine in serum
- imaging techniques: ultrasonography mostly sufficient

Clinical classification of UTI

Upper urinary tract infection (easy progression to sepsis)
- acute pyelonephritis and chronic pyelonephritis
- interstitial nephritis
- renal absces, pararenal absces
Lower urinary tract infection
- cystitis
- urethritis
- prostatitis
Treatment of UTI
- symptomatic therapy, fluid intake
- antibiotic therapy
CENTRAL NERVOUS SYSTEM INFECTIONS
(1 lesson)

Classification of CNS infections, terminology:

structure most involved: meningitis, encephalitis, myelitis, radiculitis, neuritis
type of inflammation:purulent x nonpurulent, aseptic
pathogen: bacterial, viral, fungal, parasitic
extent of inflammation:
difusse - meningitis, meningoencephalitis, encephalitis
focal necrotising encephalitis (HSV), cerebritis, abscess
course of disease: acute x chronic

Pathogenesis:
- invasion of CNS - via blood (blood-brain, blood-cerebrospinal fluid barrier)
- via direct spreading from adjacent structures
- via peripheral nerves
- response of CNS to bacterial and viral invasion
- brain edema

Clinical manifestations and etiology of CNS infections:

- meningeal syndrome (headache, vomitus, meningeal signs), fever, coma
- examination of meningeal signs
- symptoms of encephalitis
- purulent meningitis
- clinical presentation
- etiology (pneumococcus, meningococcus, listeria, other agents)
- aseptic meningitis, meningoencephalitis
- clinical presentation
- etiology (tick-borne encephalitis, respiratory viruses, borrelia, leptospira)

Diagnostics:
- diagnosis of CNS inflammation and type of inflammation
lumbar puncture, cerebrospinal fluid testing and findings
- detection of etiology dirrect and indirrect methods

Basic principles of treatment:

- causative therapy
- symptomatic therapy (including brain edema therapy)
- risk of delayed diagnosis (meningococcal invasive disease, purulent meningitis,
necrotising encephalitis)
IMPORTED INFECTIONS
(1 lesson)

Basic features of imported diseases

- infections of cosmopolitan occurrence
- infections limited to tropical and subtropical climate

Danger: delayed diagnosis

risk of spreading

Diseases obligatory reported to WHO: variola, cholera, plague, haemorhagic fevers, SARS

The most important syndromes in imported diseases:

fever: malaria, typhoid fever, dengue fever, haemorrhagic fevers, amebiasis

diarhea: food-poisoning
bacterial etiology (except pathogens common in middle Europe):
enterotoxigenic E. coli (ETEC), shigellae, V. cholerae
parasitic etiology: Entamoeba histolytica, Giardia intestinalis, Trichuris
trichuria, Ancylostoma duodenale

icterus: viral hepatitis (A,E,B), yellow fever

leptospirosis
amebic liver abscess, echinococcosis, schistosomosis

exanthema: disesases eliminated by vaccination in developed countries (measles, rubella)

diseases limited to tropical and subtropical climate (dengue, rickettsiosis,
haemorrhagic fevers, larva migrans cutanea)

Examination of traveller:
history including detailed travell history
physical examination, dominant symptom
laboratory tests: basic screening + special tests with respect to the suspected diagnosis

Malaria
endemic area
malaric plasmodia: Plasmodium vivax, ovale, malariae, falciparum
life cycle of plasmodium, insect vector (Anopheles mosquito)
clinical manifestation: attack of fever
fever patterns tertian, quartan, tropical (falciparum) malaria
danger of falciparum malaria
diagnostics: microscopy - thick smear, thin smear of blood
treatment and prevention, increasing resistance to antimalarial drugs
EXANTHEM OF INFECTIOUS ORIGIN
(2 lessons, slide show)

Introduction, terminology:
exanthem (skin), enanthem (mucosal surfaces)
infectious diseases with exanthem as an obligatory symptom and facultative symptom
pathogenesis of exanthem

Examination of patient with rash:

morphological classification of the rash, distribution, pattern of progression, timing
history: vaccination, travelling abroad, known allergy
morphologic types of skin lesions: macula, papula, nodule, vesicle, bulla, pustula

Morphologic classification of exanthems, representative diseases:

1. macular and/or papular exanthem:

scarlet fever (scarlatina)
measles (rubeola, morbilli)
German measles (rubella, rubeola)
Fifth disease (erythema infectiosum)
Sixth disease (exanthema subitum, roseola infantum)
dif. dg. allergic reaction

2. vesicular and pustular exanthem:

generalized: chickenpox (varicella)
smallpox (variola)
localized: herpes zoster
herpes simplex
impetigo

3. petechial purpuric eruptions:

rickettsiosis purpuric fever
infections associated with disseminated intravascular coagulopathy:
meningococcal invasive disease
viral hemorrhagic fevers
severe sepsis
Falciparum malaria