PEMERIKSAAN

LABORATORIUM PADA
PENYAKIT AKIBAT INFEKSI
BAKTERI DAN VIRUS
dr. Rahma Triliana, S.Ked., M.Kes., PhD Candidate
THINGS TO REMEMBER:
 THEIMMUNE SYSTEM = Reticuloendothelial System
 ANATOMY
 Bone Marrow
 Lymph (Nodes & System)
 Mucosa-Associated Lymphoid Tissue (MALT) & Tonsils
 Thymus
 Spleen
 HISTOLOGY
 Effector cells  White blood cells & its components
FUNCTION
 Immunity, Infection & Inflammation Responses
 Defend against harmful invaders (e.g. bacteria, viruses, etc).
 Sense & respond to foreign antigens or other molecular patterns that
are not “SELF”
 Clear Senescent/Abnormal cells (e.g. cancer cells)
 Immune regulation  physiological regulation in tissues
 Innate Immunity
 Non cellular immune regulation & formation (Complement, Antibody)
 Adaptive Immunity (Humoral & Cellular)
 Immune regulation (Helper Cells, Memory Cells)
 Regulation of Antibody production & Its type
 Tolerance (Peripheral & Central)
LOCATION:
MEMBRANE BOUND, CELL BOUND, SECRETORY (IgA) & CIRCULATING
DOUBLE EDGE SWORD
OF
IMMUNE RESPONSES
All the world is a Laboratory to the Inquiring
Mind
Martin H. Fischer 1879–1962
US physician and writer
Fischerisms Howard Fabing and Ray Marr (1944)
 DISEASE OF IMMUNE SYSTEM
FUNCTIONAL DEFECT STRUCTURAL DEFECT

IMMUNE ↓ NUMBER ↑ NUMBER

DEFICIT ↓ SIZE ↑ SIZE
DEFICIENT
DEFECT + DEFECT +
SUPRESS
AUTOANTIGEN +
IMMUNE TOLERANCE LOSS INFECTION
REACTIVE ↑ ACTIVITY & INFLAMMATION
Due to NON SELF
UNWANTED RX ANTIGEN
REACTION TO
INFECTIONS
Bacterial Structure
& Classification
12
Pathogenicity &
Transmission
13
If Three Simple Questions And One
Well Chosen Laboratory Test Lead
To An Unambiguous Diagnosis,
Why Harry The Patient With More?

Anonymous
Editorial, Clinical Decision By Numbers.
Lancet 1: 1077 (1975)
 AIM
 Determine present of inflammation
 Determine Infectious process
 Identify the Cause
 Finding MIB through various technique
 Finding auto-antigen or autoantibody
 Detect allergen
 Select proper treatment
 Severity & Prognosis
 INFLAMMATION TEST
 Infection +  Local Sign + fever > 38.5 oC
↑ Acute Phase Protein (+)
 C-Reactive Protein/CRP
 Lipopolysaccaride Binding Protein/LBP, etc
 Changes in Complement Level
↑ Erythrocyte Sedimentation Rate/ESR
 Complete Blood Count (CBC)
 Screening test
 Evaluation of structural & functional characteristics
CBC : PERIPHERAL WHITE
BLOOD CELL ANALYSES
 Number
Leucocytosis (> 12,000/mL)

Leucopenia (< 6,000/mL)

 Relative proportions of individual WBC 

Differential Count  type of immune response
Shift to the left (bacterial, acute inflammation)

Shift to the right (viral, chronic inflammation)

Normal Level:

Eosinofil 0–7
Basofil 0–2
Stab Neutrophil 0–4
Segment Neutro 45 – 74
Lymphocytes 16 – 45
Monocytes 4 -10
 LABORATORY INVESTIGATION OF
MICROBIAL & VIRAL INFECTIONS
 Examining
specimens to detect, isolate, & identify
pathogens or their products using:
 Microscopy (Gold standard for Bacterial Infection)
 Culture techniques (Gold standard for Bacterial Infection)
 Biochemical methods (Identification)
 Non-cultural Techniques (Identification)
 Immunological Tests  Antigen detection
 Molecular techniques (DNA/RNA testing, PCR, Sequencing etc)
 Testingserum for antibodies produced in response to
infection, i.e. serological response.
Laboratory Test
in Infection
19
 MICROSCOPY
 To assist diagnosis of microbial infections
 Examined microorganisms microscopically for
 Location (e.g. Intracellular or extracellular)
 Motility (e.g. Vibrio cholerae in a rice water faecal specimen,
Treponema pallidum in chancre fluid. Etc)
 Morphology (e.g. coccal or bacilli)
 Staining reactions
Gram Stain (Gram negative & Gram Possitive Bacteria)
Acid fast reaction Ziehl-Neelsen (Mycobacterium sp.
 Anaerobic Bacteria

Gram Positive Gram Positive

Bacilli Bacilli Cocci

Cocci

• Collinsella aerofaciens • Propionil-bacterium • B.fragilis groub • Veilonella

• Finegoldia magna spp • Other bacterioides parvula
• Micromonas micros • Actinomyces spp spp
• Peptococcus niger • Clostridium spp • Fusobacterium spp
• Peptostreptococcus • Bifudobacterium • Bilophila
anaerobius spp wadsworthia
• Schleiferella • Eggerthella lenta • Leptotrichia spp
asaccharolytica • Eubacterium spp • Porphyromonas spp
• Atopobim spp • Lactobacillus spp • Provotella Spp
• Anaerococcus spp • Mobiluncus spp
 Gram Possitive Aerobic Bacteria

Cocci Bacilli

Catalase Pos. Catalase Neg. Branching Non Brancing

• Staphylococcus Spp • Streptococcus Spp • Nocardia spp

• Enterococcus spp • Streptomyces Spp
Catalase Possitive
• Micrococcus spp
• Abiothropia spp • Rhodococcus Spp
• Leuconostoc spp • Oerscovia spp
• Lactococcus spp • Other similar • Bacillus spp
• Clobicatella spp spesies • Brevibacills spp
• Pediococcus spp • Paenibacillus spp
• Aerococcus spp
• Gamella spp
• Helcococcus spp Catalase Negative
• Alloicoccys ottidis

• Lysteria monocytogenes, Coryne-bacterium spp, Erysipelothrix spp, Lactobacillus spp,

Actinomyces spp, Arcanobacterium Spp, Bifidobacterium spp. Gardnerella Vaginalis
• Other similar organsim
 Gram Negative Aerobic Bacteria

Cocci Bacilli/microbacilli
Mc Conkey
• Neisseria gonorrhea
• Neisseria Growth + Growth (-) Requires
meningitidis Special media
• Other Neisseria spp
• Moraxella catharralis OXIDASE NEGATIVE OXIDASE VAR
• Enterobacteriaceae • Haemophylus spp • Bartobella spp
• Acinetobacter spp • Afipia spp
OXIDASE POSSITIVE
• Stenotrophomonas • Campylobacter spp
• Sphingomonas paucimobilis
maltophilia • Arcobacter spp
• Moxarella catharralis
• Other similar MIB • Helicobacter spp
• Neisseria elongata
OXIDASE POSSITIVE • Eikenella corrodens • Legionella spp
• Pseudomonas spp, Burkholderia spp • Weeksella virosa • Brucelia spp
• Achrobacter spp, Rhizobium spp, Ochrobactum • Pasterurella Soo • Bordetella pertusis
spp • Suttonella indologenes • Bordetella para pertusis
• Chryseobacterium spp, Sphringobacterium spp • Mannheimia haemolytica • Franciscella tularensis
• Alcaligenes spp, Bordetella non pertusis, • Actinobacillus Spp • Streptobacillus moniliformis
Comamonas spp • Kingella spp • Spirilium minus
• Vibrio spp, Aeromonas spp, Plesiomonas • Cardiobacterium spp
shigelloides, Chromobacterium violaceum • Capnocytophaga spp
• Other similar organsim • Other similar spesies
 CULTURE TECHNIQUE
 To isolate & identify agent of diseases
 Types of Culture Media
 Basic
 Enriched
 Selective
 Indicator
 Transport
 Identification

 To apply antimicrobial susceptibility testing.

 BIOCHEMICAL METHODS
 To
identify pathogens by use of substrates and sugars or their
enzymatic and fermentation reactions.
 Catalase test  differentiate staphylococci.
 Oxidase test  microbes producing oxidase enzymes.
 Coagulase test  differentiate Staphylococcus.
 Fermentation tests  differentiate enterobacteria
 Indole test  detect organisms that are able to break down
tryptophan to release indole.
 Urease test  identify species which produce urease enzyme.
 NON-CULTURAL
TECHNIQUES FOR
MICROBIAL DETECTION
 SEROLOGIC TEST
(ANTIGEN &/ ANTIBODY DETECTION)
 Enable early or presumptive diagnosis of bacterial/viral Infection
 Use specific antigen with antisera or labelled antibody
 Use spesific antibody with antisera or labelled antigen
 Identify pathogen from isolated culture, specimens (serum, plasma, cerebrospinal
fluid, urine, specimen extracts, washings, fluid cultures) using direct
immunofluorescence.
 Identify certain proteins produced by bacteria or virus
 Techniques to identify soluble antigens include
 Dipstick dot immunoassays.
 Agglutination techniques (direct, latex, co-agglutination)
 Enzyme immunoassays (EIA)
 Enzyme Linked Immuno Sorbent Assays (ELISA)
 Immunochromatographic (IC) tests
 Even in the hands of the greatest
physicians, the practice of medicine is
never identified with scientific
(laboratory) medicine, but is only an
application of it.

Rudolf Virchow 1821–1902

German pathologist
Quoted in ‘Medical Proverbs’ by F. H. Garrison,
Bulletin of the New York Academy of Medicine
October: 979 – 1005 (1928)
MUST KNOW INFECTIONS
BACTERIAL
 Bacteremia 3B
 Sepsis 3B
 Typhoid fever 4
 Cholera 4
 Leptospirosis 3A  Baca
 Diphteria (THT)3B  Baca
 Pertussis 4  klinis
VIRAL
 Dengue 4
 HIV-AIDS non koinfeksi 3A
 Morbilli 4  Klinis
 Varicella 4  Klinis
 Parotitis
Epidemica/Mumps 4 
Klinis
 SEPSIS & BACTERIEMIA
 Sepsis: Whole body inflammatory responses to an infections  Systemic
Inflammatory Responses Syndrome (mild, severe, septic shock)
 Bacteremia: Presence of Bacteria in blood
 Clinical Finds: Fever, HR,  RR,  BP,  consciousness (edema,  organ
functions) + Local sign
 Laboratory finding :
 Routine test
 CBC   Leucocytes (12.000, > 10% stab neutrofil ),
 Chem  coagulation dysfx (DIC), Metabolic acidosis, Organ dysfunction signs
 Specific test
  Procalcitonin
 Depend on the cause & Affected organs
 Blood culture (+) Bacteriemia
 TYPHOID FEVER
 Bacteria
 Salmonella typhi  Invade MALT in GIT
 Ag O (Body  Ig M), Ag H (flagella  Ig G), Ag Vi (Capsule  IgG)
 Clinical finds : Fever, abdominal pain, (icteric), melena,
 Laboratory finding :
 Routine test
 CBC   Leucocytes (<4.000, lymphocytosis),  Leucocytes
(sepsis) ,  Hct dan Hb
 Chem   AST &ALT
 Specific test
 Serologi (Widal)
 Blood culture
 Fecal culture
 ELISA
 PCR
 CHOLERA
• The Bacteria
• Vibrio Cholerae  motile, many strains
• Clinical find: Diarrhea (rice water stool), vomit, dehydration
syock (late)
• Laboratory finding :
• Routine test
• CBC  leucocytes, hemokonsentrasi
• Chem  Electrolytes changes, Acidosis,  GOT & GPT, Lab in dehydration
• Specific test
• Rapid dip stick test for V.Cholerae O1 and O139
• PCR
 LEPTOSPIROSIS
• The Bacteria
• Spiral Shapes bact (Leptospira Spp, 13 of 21 species is pathogen)
• Rat borne diseases (Weil diseases/Rat Cather’s yellow)
• Clinical findings : asympthomatic, fever, headaches, myalgia, bleeding
(severe case)
• Laboratory finding :
• Routine test
• CBC  leucocytes/lymphocyte, trombosit
• Chem  normal to severe depend on organ involved
• Specific test
• Microscopic Agglutination Test
• Weil Felix test
• ELISA of Ag or Ab to Leptospira
• PCR
 DENGUE
 The virus
 Arthropod borne human viral, single stranded RNA
 4 serotypes : DEN 1 - 4
 Clinical findings : fever, myalgia, rumpleleede test, bleeding sign, syock
(late)
 Laboratory finding :
 Routine test
 CBC leucocytes/lymphocyte, trombosit, hemokonsentrasi, HCT/hb > 3.5
 Chem  hemostasis test defect & electrolytes changes, liver fx test changes ( GOT >
GPT  1 - 1,5)
 Specific test Primer Sekunder Sekunder
 IgM/IgG detection Ig M (+) 3 - 5 hr (+) 3 - 5 hr (-)
 Dengue isolation Ig G (+) > 14 hr (+) 2 - 3 hr (+)
 PCR
 HIV-AIDS
• The virus:
• Human immunodeficiency virus (HIV)  Acquired Immune
Deficiency Syndrome (Clinical latency 3 - 20 years)
• Retroviridae, Lentivirus. HIV type 1 (> virulent) & HIV type 2
• Clinical findings:
• Early: Influenza like syndrome/mononucleosis like illness  immune
deficient  Opportunistic infections sign (fever etc)
• Laboratory finding :
• Routine test  usually normal in early stage
• Specific test
• HIV Antibodies detection
• CD4+ T cell count
• PCR
 Modern Medicine Is One Of Those
Extraordinary Works Of Reason:
An Elaborate System Of
Specialised Knowledge, Technical
Procedures, And Rules Of Behaviour.

Paul Starr 1949 –

Professor of Sociology, Harvard University
The Social Transformation of American Medicine
Introduction,
p.3, Paul Starr. Basic Books, New York (1982)