I

10. Orthopaedics
2. Biochemistry 11. Radiology
3. Pharmacology 12. Dermatology
4. Pathology 13. Anesthesia
5. Microbiology 14. OBG
6. FMT 15. Pediatrics
7.PSM 16.Surgery
8. ENT 17. Controversies Solved
9, Ophthalm ology
0 18. Miscellaneous
 -·-- - -- ·-- -- , , .... - .... --·· ...... - 11:-71/-• ••

EXTRA BITES
1. VON MAGNUS PHENOMENON
• A proportion of daughter virions produced may not be
infective due to defective assembly
• Such "incomplete viruses" are seen in large proportions when
cells are infected with large doses of influenza virus
• The virus yield will have a high hemagglutinin titre but low
infectivity
2. CROSS REACTIVATION OR MARKER RESCUE
• When a cell is "infected" with an active virus and a different
but related inactivated virus progeny producing one or more
genetic traits of the inactivated virus may be produced
3. LYSIS FROM WITHOUT
• When bacteria are mixed with phage particles with high
multiplicity, multiple holes are produced on the cell with
consequent leakage of cell contents.
• Bacterial lysis occurs without viral multiplication
4. ADENOVIRUS INFECTIONassociated with
• Pharyngitis
• Pneumonia
• ARDS .
• Pharyngoconjunctival fever
• Epidemic keratoconjunctivitis
• Acute follicular conjunctivitis
• Diarrhoea

Email : [email protected] I Website : www.damsdelhi.com Page I 53

Last Look Mixed Bag

• Acute hemorrhagic cystitis

• Generalized exanthema
• Mesenteric adenitis
• lntussusception
5. COXSACKIE VIRUS INFECTIONassociated with
• Herpangina (vesicular pharyngitis)
• Aseptic meningitis
• Hand foot mouth disease
• Epidemic pleurodynia/Bornholm disease
• Myocarditis/pericarditis in new born
• Juvenile DM (Coxsackie B4)
• Orchitis
• Post viral' fatigue syndrome
6.
PASCHEN BODIES Elementary bodies demonstrated by Paschen in
smears from small pox lesions
GUARNERI BODIES Eosinophilic inclusion bodies- aggregations of
virus particles in a matrix
MOLLUSCUM · Molluscumcontagiosum
BODIES
WARTH IN Multinucleate giant cells in lymphoid tissues in
FINKLEDEY CELLS Measles
COUNCILMAN Necrosed cells coalesce and become hyalinised
BODIES leading to the formation of characteristic
eosinophilic masses in Yellow fever

TORRES BODIES Acidophilic intanuclear inclusion bodies seen in

liver cells in Yellow fever
NEGRI BODIES lntracytoplasmic inclusion bodies in the
neurons, most abundant in the cerebellum and
hippocampus- composed of finely fibrillar
matrix and rabies virus particles

Email: [email protected] I Website: www.damsdelhi.com Page I 54

j
Microbiology

7. The mouth of newborn is not sterile.

8. Within 12 hrs of birth, ALPHA haemolytic streptococci are found in
the upper respiratory tract and become the dominant organisms of
the oropharynx and remain so for life
9. In normal adult colon resident bacterial flora is mostly comprised of
96-99% anaerobes
10. The Eijkman test is usually employed to find out whether the
coliform bacilli detected in the presumptive test on water are E.coli
11. Sphagetti Meatball appearance/Banana grape appearance-
Pityriasisversicolor (tineaversicolor)
12. Reynolds-Braude Phenomenon- A rapid method of identifying
C.albicans is based on its ability to form germ tubes within 2 hrs when
incubated in human serum at 37 deg C
13. Sclerotic cells- Histologically the lesions show the presence of
fungus as round or irregular dark brown yeast like bodies with septae,
seen in Chromomycosis
14. Cigar shaped- yeast cells without mycelia in tissues infected with
Sporotrichosis
15. Asteroid bodies- seen in Sporotrichosis lesions composed of a
central fungal cell with eosinophilic material radiating from it

Most common mode of transmission of Animal bites

Pasteurellamulticoda
Most common infection in Febrile Invasive candidiasis
neutropenia
Most common form of Sporotrichosis . Superficial
Most common systemic mycosis Candidiasis
. Most common cause of Tineacapitis Trichcphvtontonsurans
Most common parasitic CNS.infection Cysticercosis
in India
Most common cause of Actinomycosis A.israeli
_Most common agent responsible for Anaerobic streptococci

Email: [email protected] I· Website: www.damsdelhi.com Page I SS

Last Look Mixed Bag 8 '
Human bite infections
Most common disease due to pox virus Moll uscumcontagiosu m
infections
Most common manifestation of Acute Cervical lymphadenopathy
Toxoplasmosis
Most common site of ringworm Tineapedis {feet)
Most common cause of Tineapedis T.rubrum
Most common human disease caused Otomycosis
by Aspergillus

SOURCES OF INFECTION

Listeria Refrigerated food

Legionella Water aerosols from air
conditioners or coolers
P .multicoda Animal bite
Clostridium Canned food
Gastroenteritis within 6 hrs Preformed staphylococcal toxin
Gastroenteritis within 8 hrs with Bacillus cereus (history of rice
predominant vomiting intake from a Chinese restaurant)

CULTURE MEDIA

Levinthal and Mannitol salt agar Staphylococcus aureus

Crsytal violet blood agar Streptococcus pyogenes
Loeffler' s serum slope and Corynebacterium diphtheria
Potassium tellurite blood agar
Sabourad' s dextrose agar Nocardia
Robertson's cooked meat broth All anaerobic bacteria
PLET medium Bacillus anthracis
Thayer Martin Medium/New Gonococcus and Meningococcus
York City medium
MacConkey's agar All Enterobactericeae
Selenite F broth and Salmonella and Shigella
Tetrathionate broth

Email : info@)damsdelhi.com I Website : www.damsdelhi.com Page I 56

Microbiology

Bordet Gengue medium Bordetella pertussis

Castaneda method Bruce Ila
Cetrimide or Dettol agar Pseudomonas
LI Medium or Dorset Egg Mycobacterium tuberculosis
medium
PPLO medium Mycoplasma
Skirrow's medium Helicobacter pylori

BASH - Lotent in ectiom Bocte1io that inoPase cAMP

8: Brill Zinsser disease CAPE Dimor hie Fum i- PH(B
A: Ankylostorna
C: Choler'1 P: Penki!iium, Paracoccidiodes
A: Anthr acis H: Histoplasma
S: Slow Virus inter tions
P: Pertussis C: Cocridiodes
H: Herpes Zoster
E: E.coli B: Blastornvces

DNA VIRUSES
1. All DNA viruses areHHAPPPy viruses-
• Hepadna
• Herpes
• Adena
• Pox
• Parvo
• Papova
2. All are double stranded EXCEPT-Parvo(ie part of a virus-single
stranded)
3. All are linear EXCEPT -Papova&Hepadna(circular)
4. All are icosahedral EXCEPT-Pox(complex)
5. All replicate in nucleus EXCEPT-Pox(in cytoplasm as it carries its own
DNA dependent RNA polymerase)
6. Naked DNA viruses -PAP
• Parvo
• Adeno
• Papova

Email: [email protected]:www.damsdelhl.com Page I 57

Last Look Mixed Bag

ANATHNARAYAN AND PANICKER

8TH EDITION - BACTERIOLOGY

OIL PAINT APPEARANCE Staphylococcus aureus

ON NUTRIENT AGAR
SLOPE
PANTON VALENTINE Leucocidin (synergohymenotropic toxins)
TOXIN
HUGH LEIFSON'S To differentiate between Staphylococcus
OXIDATION REACTION and Micrococcus
BROWN Categorized Streptococcus on the basis of
their growth in 5% horse blood agar pour
plate cultures
LANCEFIELD Classified haemolytic Streptococci
serologically into groups based on the
nature of a Carbohydrate antigen on the
cell wall
PYR TEST Hydrolysis of pyrrolidonylnaphthylamide
and failure to ferment ribose are useful in
differentiating Streptococcus pyogenes
from other Streptococci
DICK TEST AND SCHUL Tl Used to identify pyrogenic exotoxin of
CARL TON REACTION Streptococcus
PIKE'S MEDIUM Blood 'agar containing 1 in 1,000,000 crystal
violet and 1 in 16,000 sodium azide -
Transport medium for Streptococcus
MAXTED'S Streptococcus pyogenes are more sensitive
OBSERVATION to Bacitracin than other streptococci
CAMP REACTION Accentuated zone of hemolysis when
(CHRISTIE, ATKINS, AND Streptococcus agalactiae is inoculated
MUNCH PETERSON} perpendicular to a streak of Staphylococcus
aureus grown on blood agar

Email: info@)damsdelhi.com I Website: www.damsdelhi.com Page I 58

Microbiology

QUELLING REACTION In the presence of homologous antiserum

the capsule of Pneumococcus becomes
apparently swollen, sharply delineated and
retractile.
WEICHSELBAUM First described and isolated Meingococcus
from the spinal fluid of a patient
MUELLER HILTON Cultivation of Meningococci
STARCH CASEIN
HYDROSYLA TE AGAR
MODIFIED THAYER Selective medium for Meningococci
MARTIN (WITH
VANCOMYCIN, COLISTIN,
AND NYSTATIN)
KOVAC'S METHOD Rubbing a little growth of Neisseria
meningitides on a strip of filter paper with
the oxidase reagent-s deep purple colour
appears immediately
WATERHOUSE Overwhelming and fatal condition
FRIDERICHSEN characterized by shock, DICand multiorgan
SYNDROME failure due to Meningococcal disease.
WATERCAN PERINEUM Gonorrhoea infection spreading to
· periurethral tissues, causing abscessesand
multiple discharging sinuses.

FITX HUGH CURTIS Gonorrhoea in women can cause

SYNDROME peritonitis, and perihepatitis (Laparoscopy
shows "violin string adhesions")

CREDE'S METHOD The practice of instilling 1% silver nitrate

solution in eyes of all newborn babies (to
prevent from Ophthalmianeonatorum)

KLESS-LOEFFLER Diphtheria bacillus was first described by

!ACILLUS (KLB) Klebs but was first cultivated by Loeffler

VOLUTIN/BABES-ERNST Polymetaphosphate granules situated at

GRANULES the poles of Diphtheria bacillus and are
-

Email: [email protected] I Website: www.damsdelhi.com Page I 59

Last Look Mixed Bag

called polar bodies. Stained by Albert's,

Neisser's and Ponder's stains.

CHINESE Bacilli seen in pairs, palisades or at angles

LETTER/CUNEIFORM to each other forming a "V" or an "L" - it is
ARRANGEMENT due to incomplete separation of daughter
cells after binary fission
PARK WILLIAMS 8 Diphtheria strain used universally for toxin
STRAIN production
ELEK'S GEL Toxins produced by the bacterial growth
PRECIPITATION TEST will diffuse into the agar and where it
meets the antitoxin in optimum amounts
will produce a line of precipitation-
Diphtheria
SCHICK TEST Susceptibility test done for Diphtheria
antitoxin
DANYSZ PHENOMENON If to a given amount of antitoxin the
equivalent amount of toxin was added all
at once the mixture remained non toxic. If
instead the same amount of toxin was
added in two or more instalments at
intervals of 15 minutes or more, the
resultant mixture was toxic.

PREISZ NOCARD BACILLI Corynebacteriumpseudotuberculosis

BACIUUS ANTHRACIS 1. First pathogenic organism to be seen
{HISTORICAL under microscope {Pollender)
IMPORTANCE} 2. First communicable disease shown to be
transmitted by incolutation of infected
blood (Davaine)
3. First bacillus to be isolated in pure
culture and shown to possess spores (Koch)
4. First bacterium used for the preparation
of an attenuated vaccine (Pasteur)
MCFADYEAN'S REACTION When blood films containing anthrax bacilli

Email: info@)damsdelhi.com I Website: www.damsdelhi.com Page I 60

 are stained with polychrome methylene
blue for a few seconds and examined under
a microscope an amorphous purplish
material is noticed around the bacilli. This
represents the capsular material and is
characteristic of Bacillus anthracis

MEDUSA HEAD Under the low power microscope the edge

APPEARANCE of the colony is composed of long
interlacing chains of bacilli resembling locks
of matted hair- Bacillus anthracis
INVERTED FIR TREE Seen in bacillus anthracis on gelatin sub
APPEARANCE culture with slow liquefaction commencing
from the top
STRING OF PEARLS When B anthracis is grown on the surface
REACTION of a solid medium containing 0.05-0.50
units of penicillin/ml, in 3-6 hrs the cells
become large, spherical, and occur in
chains on the surface of the agar. This
reaction differentiates clearly B anthracis . \
from B cereus and other aerobic spore
bearers
STERNE STRAIN OF Live attenuated anthrax spore vaccine
BACILLUSANTHRACIS strain obtained by loss of plasmid (p x 02)
which controls capsule production leading
to loss of virulence
HIDE PORTER'S DISEASE Cutaneous anthrax (malignant pustule)
WOOL SORTER'S DISEASE Pulmonary anthrax
ASCOLl'S If the sample received is putrid so that the
THERMOPRECIPITIN TEST viable anthrax bacilli are unlikely, the
diagnosis can be established by this test by
demonstration of anthrax antigen in the
~ tissue extracts
MAZUCCHI VACCINE Spores of stable attenuated Carbazoo

Email : [email protected] I Website : www.damsdelhi.com Page I 61

 ' '

' '

,~!!!.it~~?~,.~i~;~"Q\~t~!,, , "' ,,,,dUM.M.kSx '"· '&JUM£h·b"'""'""''"'''·'·<fa··''"""''·''''··dL%S . .A., . d!UL.<>,x·,·-.A,,.,,.,,,,.;Lt,.,.,m,,,.;,,,.,h,.,,)2.kxSJ.«d!!i,,AI,.,L . ,MMAJ~

-
strain of anthrax bacilli in 2% saponin
-

MYPA MEDIUM Useful in isolating Bacillus cereus from

{MANNITOL EGG YOLK feces and other sources
PHENOL RED POL YMYXIN
AGAR)
NAGLER'S REACTION Specific lecithinase effect used as a test for
the rapid detection of Clostridium
perfringes in clinical specimens

GAS GANGRENE Malignant edema; Anaerobic myositis;

Clostrid ial myonecrosis
MACLENNAN Anaerobic wound infections
CLASSIFICATION
CITRON BODIES Clostridium septicum
FL/DE'S TECHNIQUE If the water of condensation at the bottom
of the slope of a nutrient agar is inoculated
with mixed cell culture after incubation
anaerobically for 24 hrs subcultures from
the top of the tube will yield a pure growth
of the tetanus bacillus
DODERLEIN'S BACILLI Lactobacillus present in vagina
SIGNIFICANT In the presence of active infection in the
BACTERIURIA urinary tract the urine will contain 100,000
bacteria or more per ml
ALKALESCENS-DISPAR EIEC were grouped under this group before
GROUP
BALLERUP BETHESDA Citrobacterfreundii strains were formerly
GROUP classified under this group. They exhibit
extensive antigenic sharing with
Salmonellae
FRIEDLANDER'S Klebsiella pneumonia; Bacillus
BACILLUS mucosuscapsulatus
GAY BOWEL DISEASE Sexuallytransmitted perianal and rectal

Email : [email protected] I Website : www.damsdelhi.com Page I 62

Microbiology £.QJ,. , . . ~ £. .; ;_ .
'~

diseases- shigellosis may be a part of it

SACH'S BUFFERED Transport medium for fresh feces for

GLYCEROL SALINE detection of Shigella

EBERTH GAFFKY Salmonella typhi

BACILLUS
WILSON AND BLAIR Jet black colonies with a metallic sheen are
BISMUTH SULPHIDE formed due to presence of H2S
MEDIUM
BOIVIN ANTIGEN O antigen of Salmonella extracted from the
bacterial cell wall by treatment with
trichloroacetic acid as first shown by Boivin
KAUFFMAN WHITE Salmonella
CLASSIFICATION
DREYER'S Narrow tube with conical bottom used for
AGGLUTINATION TUBE H agglutination in Widal reaction
FELIX TUBE Short round bottomed tube for 0
agglutination in Widal reaction
CRAIGIE AND YEN Bacteriophage typing for S. typhi
FISH IN STREAM In stained films of mucus flakes from acute
APPEARANCE cholera cases the vibrios are seen arranged
in parallel rows; described by Koch
SWARM OF GNATS . When acute cholera stool or a young
APPEARANCE culture is seen under the microscope the
actively motile vibrio with their darting
motility suggest a swarm of gnats
TRANSPORT MEDIA FOR 1. VenkatramanRamakrishnan medium (VR)
CHOLERA 2. Cary Blair medium
3. Autoclaved sea water
ENRICHMENT MEDIA 1. Alkaline peptone water
FOR CHOLERA 2. Monsur'staurocholatetellurite peptone
~ water

Email : [email protected] I Website : www.damsdelhi.com Page I 63

Last Look Mixed Bag . ~Mt .2. " ,. . l
.W. -1 ...

PLATING MEDIA FOR 1. Alkaline bile salt agar

CHOLERA 2. Monsur's
ge I at i nta u roe ho I a tet rypt i ca sete 11 u rite agar
(GTTA medium)
3. TCBS medium (thiosulfate, citrate, bile
salts and sucrose)

COPROANTIBODIES lgG, lgM and lgA seen in feces in case of

cholera
KANAGAWA Strains of Vibrio parahaemolyticus isolated
PHENOMENON from environmental sources are nearly
always non haemolytic when grown on
special high salt blood agar (Wagatsuma
agar) while strains from human patients are
almost always haemolytic. It is due to a
heat stable haemolysin. It is used as a test
for pathogenicity- Kanagawa positive
strains are considered pathogenic for
humans and negative are non-pathogenic
BLUE PUS Pseudomonas aeruginosa
SHANGHAI FEVER Self limiting febrile illness resembling
typhoid occurring in tropical areas due to
Pseudomonas aeruginosa

WHITMORE'S BACILLUS Burkholderiapseudomallei/ Actinobacillusw

hitmori/Malleomycespseudomallei/Loeffler
ellapseudomallei

SAFETY PIN APPEARANCE 1. Burkholderiapseudomallei

2. Yersinia pestis
3. Calymmatobacteriumgranulomatis
{Donovaniagranulomatis)

STALACTITE GROWTH If grown in a flask of broth with oil or ghee

(clarified butter) floated on top (ghee
broth) a characteristic growth that hangs
down into the broth from the surface- seen
in case of Yersinia pestis
"

Email : [email protected] I Website : www.damsdelhi.com Page I 64

PFEIFFER'S BACILLUS Haemophilus influenza

SA TELLITISM When Staphylococcus aureus is streaked

across a plate of blood agar on which a
specimen containing H influenza has been
inoculated after overnight incubation the
colonies of H influenzae will be large and
well developed alongside the streak of
staphylococcus and smaller further away. It
demonstrates the dependence of H
influenzae on the V factor which is
available in high concentrations near the
staphylococcal growth and only in smaller
quantities away from it

FILDE'S AGAR Best for primary isolation of H inlfuenzae

and gives a copious growth

KOCH WEEK'S BACILLUS Haemophilusaegyptius

SCHOOL OF FISH/RAIL Haemophilusducreyimaybe arranged in

ROAD TRACK small groups or whorls or in parallel chains
APPEARANCE
HACEK GROUP OF Fastidious slow growing bacteria, normally
BACTERIA resident in the mouth which 'can
sometimes cause severe infections
particularly endocarditis
1. Haemophilus species
2. Actinobacillus
3. Cardiobacterium
4. Eikenella
5. Kingellakingae

THUMB PRINT In culture films, Bordetella pertussis tends

APPEARANCE to be arranged in loose clumps with clear
spaces in between
BORDET GENGOU Bordetella perussis
BACILLUS
-

Email : [email protected] I Website : www.damsdelhi.com Page I 65

. . . ,.· ....... ········
-
BISECTED Bordetella colonies on Bordet Gengou
PEARLS/MERCURY DROP medium
APPEARANCE
ALUMINIUM PAINT Confluent growth pattern seen in
APPEARANCE Bordetella colonies

WHITE PLAGUE/THE Tuberculosis

CAPTAIN OF All THE
MEN OF DEATH
PETROFF'S METHOD Concentration method used for sputum in
TB
SWIMMING POOL OR Warty skin lesion caused by
FISH TANK GRANULOMA Mycobaceriummarinum
BATTEY BACILLUS Mycobacterium intacellulare
SCROFULA Cervical adenitis caused by M scrofulaceum
in children
TAP WATER Mycobacterium gordonae
SCOTOCHROMOGEN
GLOB/ Lepra bacilli which appear as agglomerates-
bacilli bound together by a lipid like
substance
CIGAR BUNDLE Parallel rows of lepra bacilli in the globi
APPEARANCE
REITER'S STRAIN Widely used strain of Treponemapallidum
as antigen in group specific treponemal
tests for thediagnosis of syphilis
JAR/SCH HERXHEIMER Penicillin treatment in syphilis- liberation of
REACTION toxic products like TNFs from the massive
destruction of treponemes
-
ERYTHEMA MIGRANS First stage of localized infection in Lyme's
(BULL'S EYE RASH) disease
-
DINGER'S RING Dense growth of Leptospira in semisolid
-

Email : [email protected] I Website : www.damsdelhi.com Page I 66

 media characteristically a few millimetres
below the surface

EMJHMEDIUM Ellinghausen, McCullough, Johnson and

Harris medium for Leptospira

UMBRELLA HANDLE Hooked ends of Leptospira

APPEARANCE

FRIED EGG APPEARANCE Central opaque granular area of growth

extending into the depth of the medium
surrounded by a flat translucent peripheral
zone seen in Mycoplasma colonies
WALKING PNEUMONIA Mycoplasma pneumonia
SUN RAY APPEARANCE Sulphur granules of Actinomycosis are
bacterial colonies and will be found to
consist of a dense network of thin gram
positive filaments surrounded by a
peripheral zone of swollen radiating club
like structures presenting a sun ray
appearance. The clubs are believed to be
antigen antibody complexes
SPIDERY COLONIES Actinomyces Israeli produces them on
solid media in 48-72 hrs
ANTON TEST Instillation of Listeria into the eyes of
rabbits produces keratoconjunctivitis
HAVERHILL FEVER Rat bite fever; also called erythema
arthriticumepidemicum

MORAX- AXENFIELD Moraxella lacunata

BACILLUS
GAOL FEVER Epidemic typhus; Classicaltyphus;
Louseborne typhus

~BRILL ZINSSER DISEASE

Recrudescent typhus
NEILL MOOSER OR THE When male guinea pigs are inoculated
TUNICA REACTION intraperitoneally with blood from a case of

Email : [email protected] I Website : www.damsdelhi.com Page I 67

Last Look Mixed Bag
··-::·:·.. , ...................

endemic typhus or with a culture of R typhi

they develop fever and characteristic
scrotal inflammation. The scrotum
becomes enlarged and testes cannot be
pushed back into the abdomen because of
inflammatory adhesions between the
layers of tunica vaginalis.
Reaction negative with R prowazekii

ZOONOTIC TETRAD Establishment of microfocus of Scrub

typhus needs four factors- coexistence and
intimate relationship between 0
tsutsugamushi, chiggers, rats and
secondary or transitional forms of
vegetation

OROYA FEVER/ Bartonellabacilliformis

CARRION'S DISEASE
TRENCH FEVER/FIVE DAY Bartonella (Rochalimaea) Quintana
FEVER
CAT SCRATCH DISEASE Bartone II ah ense la e
ENERGY PARASITES Chlamydiae- since they lack enzymes of the
ETC and require ATP and nutrient resources
from host cells
HALBERSTAEDTER- Inclusions demonstrated in conjunctiva]
PROWAZEK OR HP scrapings after staining with Giemsa,
BODIES Castaneda or Machiavello methods
SWIMMING POOL Inclusion conjunctivitis
CONJUNCTIVITIS
MIYAGAWA'S Elementary bodies seen in smears of
GRANULOCORPUSCLES material aspirated from bubos in LGV
LCL BODIES/LEVINTHAL Inclusion bodies seen in Psittacosis
COLE LILLIE BODIES

Email : [email protected] I Website : www.damsdelhi.com Page I 68

Microbiology

IMMUNOLOGY:
Factors that determine immunogenicity of an antigen:
1) Foreignness
2) Molecular size [>10,000 Da = lmmunogenic; <5,000-10,000 =non
immunogenic like HAPTENS]
3) Chemical composition [proteins> polysaccharides> lipids> nucleic
acids]
4} Susceptibility to processing and presenting.
ADJUVANTS(Latin: adjuvare, to help) increases immunogenicity by any
of the following 4 mechanisms: 1) Prolonged Ag persistence 2)
Enhancement of co-stimulatory signals 3) Increased local inflammation .
[granuloma formation] 4) Increased Lymphocytic proliferation.
Question: Serum from rabbits' immunized with ovalbumin were
divided in two aliquots (parts). Electrophoresis of one part gave 4
peaks i.e. albumin and alpha, beta & gamma globulins. Other part
gave a significant less gamma globulin peak on electrophoresis after
reacting with ovalbumin and removing the precipitate. The most likely
isotype that developed in these rabbits is
a) lgM
b) lgG
c) lgA
d) lgE

lmmunogenicity is the ability to induce humeral or cell mediated

immune response. While Ag may or may not (HAPTEN) behave as
immunogen. [we discussed the factors which make and Ag behave as
immunogen]

The classic experiment of A. Tiselius and E.A. Kabat in 1939 proved

that Ab were present in non albumin serum protein fractions. Now we
know that lgG is mainly found in the gamma globulin fractions while
some of it and other isotypes are present in the alpha & beta fractions
as well. OVALBUMIN is a protein derivative from egg with a molecular
weight of 44,000 Da and used as a carrier protein to haptens. Here the
decrease in gamma globulin peak suggest lgG has been precipitated.
Don't get confused with experimental animals, even immune-
competent mice would behave in similar manner. In humans too we

Email : [email protected] I Website : www.damsdelhi.com ·

Last Look Mixed Bag

would get similar response. The allergic response in humans if

developed is not lgE mediated but delayed type.
Answer will be lgG

T cells mature in the thymus by positive selection in the cortex

ensuring MHC restriction followed by negative selection in the
medulla ensuring self tolerance. MARKERS to be remembered: Pro li
cells-CD7; Pre T cells CD7, CD2, cytoplasmic CD3; Immature T cells-
CD7, CD2, CD3, CDl, CD4, CD8, TCR. Mature T cells-All the markers as
in immature T cell BUT either CD4 or CD8.

Question: A 1 year old boy with fish mouth appearance presents with
history of recurrent cyanotic spells. His mother says that on the very
first day of birth too he showed similar symptoms accompanied by
seizures. On immunological evaluation which would be the only
isotype detected in this boy.
a) lgM
b) lgG
c) lgA
d) lgE

LET'S LOOK at positive & negative selection essential for generation of

mature T cells: Positive selection in thymic cortex allows the T cells·
which recognize MHC molecule to survive and the T cells which fail to
recognize are programmed to die by apoptosis in 2-3 days. The
protective signal for survival is given for those T cells which come in
contact with the thymic stromal epithelial cells (which have MHC Ag
on their surface).---- THIS ENSURES MHC RESTRICTION----------AS
THESE CELLS ARE ALLOWED TO SURVIVESO POSITIVESELECTION.
Negative selection occurs in medulla to eliminate those positively
selected cells bearing high affinity receptors for MHC by the
macrophages and dendritic cells so that the mature cells do not
produce immune response to self Ag.------------------THIS ENSURES SELF
TOLERANCE----------------AS THESE CELLS ARE REMOVED SO NEGATIVE
SELECTION.

Email : [email protected] I Website : www.damsdelhi.com Page I 70

Indeed Di George Syndrome, failure of development of 3rd & 4th
pharyngeal pouch leading to thymic aplasia and hypoparathyroidis~.
That's why facial (fish mouth due to high arch) & cardiac abnormalities
(leading to cyanotic spells) and hypocalcaemia (seizure at birth). NOTE:
No thymus-No TH2 cell-No class switching-ONLY lgM
Primary lymphoid organs: MATURATION (lymphopoiesis) & Secondary
· lymphoid organs (site of Ag EXPOSURE)
A 6 year old boy is suffering from recurrent infections with capsulated
and Gram negative organisms. lmmunophenotyping results are normal
for all cell types except deficient CD19 & CD21 on the B cells. All of the
following are true except?
a) B cells can recognize the Ag
b) T cells can bind to the Ag
c) B cells cannot proliferate in response to the Ag
d) T cells cannot bind to the Ag

T cells can bind to Ag is false/incorrect. Well lets look at the Antigens

involved in this question. Polysaccharides (capsule) & LPS (in Gram -ve
organisms) are the Tl Ag (Thymus independent Ag) which show weak
immune response, no memory development, no class switching (So
Only lgM) & no affinity maturation as they cannot be processed by the
APC and presented to T cells (APC can process only proteins) unlike
the thymus dependent antigens (TD). Tl Agar~ of two types: Tl-1 Ag
_(LPS of Gram -ve org) where no TH cells or cytokines are required to
stimulate B cells & Tl-2 Ag (Polysaccharide capsule, proteins) where TH
cells are not directly involved but secrete only cytokines to activate B
cells. Other options: B cells recognise all types of Ag (Proteins,
polysaccharide capsule, LPS etc). B cells cannot proliferate as the
signal transduction molecules are deficient (CD19& CD21)-leading to
these infections in this boy. T cells usually bind to protein processed by
APC

The idiotype (Amino terminal) is the Ag recognition molecule on the B

cell. (lgM & lgD) and T cell {TCR). B cells recognize unprocessed Ag
while T cells recognize Ag processed and presented by Antigen
pres~nting cells {APC) within MHC class 11 groove. The isotype (Carboxy
terminal) region of the Ag recognition molecules determines the effect

Email: [email protected] I Website : www.damsdelhi.com G

Page I 71
Last Look Mixed Bag

for which signal transduction molecules play an important role. For B

cells it is the lg alpha, lg beta, CD19 & CD21 and for T cells it is CD3

A 6 year old boy is evaluated for an immunological defect and is found

to have increased number of immature B cells with no mature B cells.
However fluorescent labeled monoclonal Ab to MHC II, CD19, CD21
and CD40 give a positive signal. What is the most likely defect in this
boy.
a) lsotype class switching
b) Alternative RNA splicing
c} Allelic exclusion
d) Somatic hypermutation

Ans: b) i.e. Alternative RNA splicing. First let's try and see why we got
it wrong. Look the enterprising thing was that most of u were thinking
in the right direction. It's one step more in immunology and that's
where it can get slightly messy. We all got confused with Class
switching, isn't it? REMEMBER SWITCH REGIONS ARE LOCATED AFTER
DELTA GENE. Therefore isotvpic class switching by gene
rearrangement (looping out the intervening genes by splicing followed
by excising & degrading those genes) leads to B cells producing lgG,
lgA & lgE only.
Next let's try and diagnose this condition: B cells are not fully mature
here. Maturation of B cells in the following order: (the markers in
BOLD to be REMEMBERED)
Lymphoid stem cells
Pro B cell (progenitor): tdt, MHC II, CD19, CD20, CD21, CD34, CD40
Pre B cell (precursor): Cytoplasmic u chains, tdt, MHC II, CD19, CD20,
CD21, CD40
Immature B cell: Surface lgM, tdt, MHC II, CD19, CD20, CD21, CD40
Mature B cell Surface : lgM & lgD, tdt, MHC II, CD19, CD20, CD21,
CD40
Blast stage (activated): Surface lgM & lgD, tdt, MHC II, CD19, CD20,
CD21, CD40
Memory B cells: Surface lgG, lgA, lgE
Plasma cell: Cytoplasmic lg

Email : [email protected] I Website : www.damsdelhi.com Page I 72

Immature B cells in this boy means there is only lgM isotype expressed
on the B cell surface and NO lgD. Alternative RNA splicing is the
mechanism by which either delta or u chain will be on a single idiotype
formed by gene rearrangement (That's why alternative splicing). Here
due to lack of this mechanism mature B cells expressing both lgM &
lgD are not formed.
Why other options are not appropriate here?
lsotype class switch will allow the expression of other isotypes by B
cell like lgG, lgA & lgE only on activation by Th cell.
Allelic exclusion is absolutely essential for specificity of idiotypes. This
allows expression of either parental chromosome and NOT BOTH.
Both are expressed for MHC I & MHC II known as allelic codominance,
as I had mentioned in previous posts.
Affinity maturation by somatic hypermutation is a beautiful
mechanism by which the immune response gets better with the time
and Ab binds more efficiently with Ag. The B cells stimulated by the
Th2 cells gets class switched and proliferates in the germinal centers
of the lymph nodes and spleen. During proliferation the possibility of
point mutations in the variable region of Ag recognition molecules
. (idiotypic region) increases. If the affinity of the new variable region
towards Ag increases then that B cell clone will be selected and the
previous clones deleted. (we all strive for the better don't we) AND
that's the reason why lgM has the least affinity (no chance of mutation
because the B cells get class switched) and has the highest avidity
(highest valency i.e. 10 meaning more binding sites)
Gosh such a long post. Who's gain 2 remember all that. Exactly!! JUST
REMEMBER the important markers in B cell maturation (will help u
guys in cancer immunology too). Pre B cell: cytoplasmic u chains· I
Immature B cells: surface lgM only; Mature B cells: BOTH surface lgM
& lgD; Memory B cells: Surface lgG, lgA & lgE; Plasma cells:
cytoplasmic lg
The innate immunity present intrinsically is non specific with limited
diversity and no memory response in contrast to adaptive immunity
which is inducible, with high diversity, memory response,
differentiation between self and non-self Ag recognition and self
limiting.

.!
Email : info@damsdelhicom I Website : www.damsdelhi.com
Page I 73
Diversity of hundred million in an immuno-competent individual is
determined by
a) ldiotypes
b) lsotypes
c) Allotypes
d) Haplotypes

ldiotype being the Ag recognition site on the Ag recognition molecule

of B cells and T cells has to have huge amount of variability to create
the diversity. This variability is created by the following mechanisms:
1) Gene rearrangement of the various gene segments coding for the
variable domains of lg and TCR. (V, D & J for Heavy and beta chain
of B & T cells respectively; V & J for light and alpha chain of B & T
cells respectively)
2) Combination of these polypeptide chains
3) Random nucleotide insertions by terminal deoxyribonuclease
transferase (tdt) enzyme
4) Mutation in the variable domain of these chains leading to
preferential selection and affinity maturation (somatic
hypermutation)
tissue incompatibility is due to codominant expression of MHC alleles
resulting in different antigenic expression on the cells. Therefore
autograft is the only graft which does not require irnmunosuppresston.
GVHD arising after BM transplant can be seen in patients suffering
from
a) bare lymphocyte syn
b) Di George syn
c) Leucocyte adhesion deficiency syndrome
d) acquired immunodeficiency syn
Most appropriate answer is c) Leucocyte adhesion deficiency
syndrome. LET'S FOLLO this: BM transplants (hematopoietic stem cell
transplant) is given to recipients to reconstitute the myeloid, erythroid
and lymphoid cells as it is a source of pluripotent hematopoietic stem
cells. Irradiation before transplant is necessary to ablate the mature T
cells which may also be present. GVHD is a complication associated
with these transplants if mature T cells persisting in the BM destroy
the allogeneic MHC bearing cells of the recipient. Therefore GVHD is
not seen in AIDS, MHC II deficiency known as Bare lymphocyte
syndrome, SCIO, Di George syndrome as the CD4 cells are deficient.
Leucocyte adhesion deficiency (LAD) syndrome is a defect in
phagocytic system where absence of chains of integrins (absence of
CD18) result in inability of leucocytes to extravasate to the site of
injury. LAD can be treated by bone marrow transplants and GVHD can
result as a complication as the T cells are normal.
A patient of ALL develops rash with desquamation, jaundice,
diarrhoea and GI bleeding after undergoin transplantation. What is the
most phenomenon occuring in this patient.l)hyperacute graft
rejection2)Acute graft rejection 3 )graft versus host disease
4)accelerated graft rejection
Now let's revise and remember the mechanisms of different
rejections: Hyperacute (minutes to hours)-preformed Ab against
donor cells AND complement activation(type II hypersentivity)
Accelerated-memory T cell activation. Acute-Primary T cell activation
and destruction by cytotoxic Tcells(Tc), macrophages and Ab. Chronic-
both T and B cell mediated. This is a case of GVDH as mature Tcells are
destroying allogeneic MHC bearing cells of recipient resulting in these
classical systemic manifestations. That's why this is asso. with BM
transplants (immunocompetant cells) so often if mature Tcells are not
removed.

Tissue compatibility testing is done to prevent graft rejection. ABO

blood typing is the first step in all tissue transplants to prevent
hyperacute rejection, followed by microcytotoxicty test to identify HLA
class I Ag, followed by mixed lymphocytic reaction to identify H LA class
11 Ag. Question: routine HLA typing must be carried out for the
following loci except
a)HLA-A b)HLA-B c)HLA-C.d)HLA-DR

HLA-A, HLA-B, and HLA-DR are the loci which indicates possibility of
transplant rejection

Email : [email protected] I Website : www.damsdelhi.com Page I 75

Last Look Mixed Bag

Monoclonal Ab to prevent graft rejection: 1) anti C028 Fab-induce

anergy (costimulatory signal between C028 on Tcell and B7 on Bcell
blocked) 2) anti CD40 ligand and anti-lL2 receptor inhibits proliferation
of Tcells 3) anti CD3 destroys Tcells.
Question:postsurgical treatment in corneal transplant recipient is a)
methotrexate b) corticosteroids c) monoclonal Ab d) No treatment
reqd.
Option d is the right answer. Eye, uterus, testes, brain and thymus are
immuno privileged sites. They do not possess lymphatic vessels. So the
alloantigens of the graft are not able to sensitize the recipient's
lymphocytes.
Stem cells can develop into more differentiated cells and they are self-
renewing as each division of a stem cell creates at least one stem cell.
Four levels of stem cells can be recognized: totipotent, pluripotent,
multipotent, and unipotent.
Totipotent cells can give rise to an entire organism.
Pluripotent stem cells arise from totipotent cells and can give rise to
most but not all of the cell types necessary for foetal development.
Multipotent and unipotent stem cells differentiate from pluripotent
stem cells. Multipotent stem cells can give rise to only a limited
number of cell types and unipotent cells to a single cell type.

Most of the donor haematopoietic stem cells (HSCs) transplanted

from a woman to a genetically unrelated man whose hematopoietic
system was totally destroyed by a combination of radiation and
chemotherapy differentiate into hematopoietic cells and some
differentiate into cells of the pancreas, liver, and heart. What would
be the most likely outcome.

a) The T cells from the donor HSCs do not attack the pancreatic,
heart, and liver cells that arose from donor cells, but mount a GVH
response against all of the other host cells.
b) The T cells from the donor HSCs mount a GVH response against all
of the host cells.
Microbiology

c) The T cells from the donor HSCs attack the pancreatic, heart, and
liver cells that arose from donor cells, but fail to mount a GVH
response against all of the other host cells.
d) The T cells from the donor HSCs do not attack the pancreatic,
heart, and liver cells that arose from donor cells and fail to mount a
GVH response against all of the other host cells.

See the most common HSC transplant is carried out by Pluripotent

cells which are immature (express CD34) and are yet to differentiate.
Thats why it is preferred over Bone marrow these days as bone
marrow contains some mature cells as well resulting in GVHD. Here
the donor hematopoietic stem cells (HSCs) differentiate into T & B
cells in an environment that contains antigens characteristic of both
host & donor leading to tolerance. So the correct answer is d) The T
cells from the donor HSCs do not attack the pancreatic, heart, and
liver cells that arose from donor cells and fail to mount a GVH
response against all of the other host cells.

Endogenous (intracellular) antigens (e.g., viral, intracellular pathogens,

tumour proteins produced in altered self-cells etc.) are degraded in
the cell cytoplasm by proteosome and then expressed on cell surface
with MHC class I proteins.
Exogenous (extracellular) antigens are endocytosed and degraded by
antigen-presenting cells followed by presentation to T cells with M HC
class II proteins.

The protein which prevents the presentation of endogenous Ag along

with MHC class II to the T cells thereby preventing autoimmune
response is.
a) TAP (Transporter associated with Ag processing) proteins
b} Proteosome
c} Invariant chain
d} Beta 2 microglobulin

zz~~'*
Email : [email protected] I Website : www.damsdelhi.com Page I 77
Ovalbumin is a commonly used experimental Ag (44000 Da size) in
immunology. One of its use is as carrier protein to certain haptens to
form the hapten carrier conjugates for immunological studies.

Question: Gluteraldehyde treated APC when incubated with native

ovalbumin and ovalbumin partially digested with enzymes when
exposed to ovalbumin specific TH cells and B cells would result in all
except
a) Native ovalbumin would activate the T cells
b) Native ovalbumin would not activate the T cells
c) Digested ovalbumin would activate the T cells .
d) Digested ovalbumin with azophenylarsonate would activate the B
cells
Yes answer is a. Native ovalbumin cannot be processed by
gluteraldehyde treated APC into small peptides as gluteraldehyde
alters the proteosome function of APC. however digested peptides can
be presented for activation of T cells. Also azophenylarsonate acts as
carrier protein to increase the size of ovalbumin (44000 Da) a hapten
to more than 100000Da to make it immunogenic to activate B cells

SOME FUNGAL DISEASES FAMOUS BY THEIR ENDEMIC NAMES

1. Blastomycosis- North American hlastomycosis/Chicago
disease/Gilchrist disease
2. Paracoccidiomycosis- South American blastomycosis/Lutz-
Splendore-de Almeida disease
3. Coccidiomycosis- California disease/Valley fever/Desert rheumatism
4. Histoplasmosis- Ohio valley fever/Darling's disease/Spelunker's lung

Email : [email protected] (Website : www.damsdelhi.com Page I 78