Clinical Pathology Nicoprieto

Front 1

Name the test and what it is for

Back 1

Catalase test
Differentiate:
- Staphylococcus (+) from Streptococcus (-)
- Among small non-branching, non-spore forming aerobic gram positive bacilli:
( + ) Listeria spp. Corynebacterium spp.
( - ) Erysipelothrix rhusiopathiae (H2S+), Arcanobacterium haemolyticum

Front 2

Name the test and what it is for

Back 2

Coagulase tube test: detects free coagulase producing organisms
Coagulase-positive staphylococci:
Staphylococcus aureus subsp. anaerobius
S. a. aureus
S. a. delphini
S. hyicus
S. intermedius (dog bite)
S. lutrae
Staphylococcus schleiferi subsp. coagulans

Coagulase-negative staphylococci:
S. saprophyticus
S.cohnii subsp. cohnii
S. cohnii subsp. urealyticum
S. captitus subsp. captitus
S. warneri
S.hominis
S.epidermidis
S. caprae
S. lugdunensis (+ with bound/slide coagulase test and PYR+)
Coagulase test = Rabbit plasma + organism incubated at 35*C and checked at 4 hr and 24 hr

Front 3

Name the test and what it is for

Back 3

Coagulase slide test: detects bound (clumping factor) coagulase producing organisms

S. aureus group and S. lugdunensis ( - coagulase tube test)

Front 4

Name the test and what it is for

Back 4

Coagulase latex agglutination test: detects bound (clumping factor) coagulase producing organisms

S. aureus group and S. lugdunensis ( - coagulase tube test)

Front 5

Name the test

Back 5

Kirby-Bauer disk diffusion antibiotic sensitivity testing showing nosocomial MRSA

Front 6

Name the test

Back 6

Kirby-Bauer disk diffusion antibiotic sensitivity testing showing community acquired MRSA with positive D-test

Front 7

Novobiocin disk/gram stain, name the organism on the right side

Back 7

Staphylococcus saprophyticus

Coagulase - Staph. involved in approximately 10-20% of UTI (young females)

Front 8

Name the probable organism

Back 8

Clostridium perfringens showing double zone of Beta hemolysis on SBA

Front 9

Lecithin Lactose Agar

Back 9

Clostridium perfringens precipitates lecithin around colonies (opaque halo)

Front 10

thioglycolate broth

Back 10

Clostridium perfringens in thioglycolate broth, showing gas production

Front 11

Name organism

Back 11

Pseudomonas aeruginosa on BAP showing metallic haze colonies

Front 12

Mac Conkey agar

Back 12

Pseudomonas aeruginosa on MAC
Glucose non-fermenter, oxidase positive

Front 13

KIA/TSI tube, organism?

Back 13

K/K:
non-glucose, non-lactose, non-sucrose fermenter
No H2S

Pseudomonas

Front 14

Type of hemolysis, possible organisms

Back 14

Beta-hemolysis

Groups
A (pyogenes)
C (S. dysgalactiae Subs. equisimilis)
G (S. equi Subs. zooepidermicus)

B (pyogenes)
β-hemolytic enterococci

Front 15

Bacitracin test

Back 15

Group A Streptococcus (pyogenes) is susceptible to Bacitracin

Bacitracin resistant Beta-Hemolytics
S. milleri group (F)
S. dysgalactiae Subs. equisimilis (C)
S. equi Subs. zooepidermicus (G)
β-hemolytic enterococci

Front 16

PYR test

Back 16

Positive in Streptococcus pyogenes (GAS)

AND Beta-hemolytic Enterococci

Front 17

Lancefield testing caveat

Back 17

Does not distinguish between large-colonyforming,
pyogenic streptococci of groups A, C and G and
small-colony-forming group A, C and G strains of the
anginosus or “S. milleri” group

Front 18

This bacterium grew in Regan-Lowe medium forming round, domed, mercury-silver, colored, shiny colonies

Back 18

Bordetella pertussis

Culture sensitivity:

• If ≥14 days from onset of cough, sensitivity is
lower, so serology is sent instead of culture

• Caveat: Serology is uninterpretable in immunized
or unimmunized patients <11 years of age
– These patients are cultured regardless of duration of
symptoms

Front 19

Name organism

Back 19

Corynebacterium diphtheriae

Non-motile
Catalase +

Front 20

Name organism and medium

Back 20

Tellurite-containing medium, black colonies of Corynebacterium diphtheriae

Front 21

Optochin Susceptibility Test, name organism

Back 21

Streptococcus pneumoniae

Optichin sensitive, > 14 mm. inhibition

Front 22

BHI agar, what is preferable for this organisms?
Name organisms:
Green arrow
Red arrow
Blue arrow

Back 22

Preferable medium for Haemophilus spp.:
Chocolate agar or Horse blood agar with free X (hemin) and V (NAD)
Red (X and V)
H. influenzae
H. haemolyticus
Green (V only) - ("The P's like the V")
H. parainfluenzae
H. paraheamolyticus
Blue (X only) - ("X-Rated")
H. ducreyi

Front 23

S. aureus streak

Back 23

Haemophilus spp. satellitism

S. aureus produces V and if Beta-hemolytic releases X from SBA

Front 24

Gram + methylene blue: name organism

Back 24

Corynebacterium diphteriae

Metachromatic granules with methylene blue

Front 25

BYCE medium, name organism

Back 25

Legionella pneumophila

Buffered Charcoal Yeast Extract agar

Legionella won't stain with gram on direct specimens, it will from subculture specimens

Front 26

Facultative anaerobes, Acid Fast negative, organism group?

Back 26

Actinomyces spp.

Front 27

Molar tooth colonies

Back 27

Actinomyces israelii

Front 28

Acid fast stain

Back 28

Nocardia spp

Front 29

Chalky-white colonies when young then yellow/orange colonies

Back 29

Nocardia asteroides

Front 30

Medusa-head colonies

Back 30

Bacillus anthracis

Front 31

Name organism

Back 31

Bacillus anthracis

Front 32

Name organism

Back 32

Bacillus anthracis

Front 33

Optichin disks

Back 33

Resistant

PYR positive, Bile esculin positive: Enterococcus spp.

PYR negative:

Bile esculin positive: S. bovis (D)
Bile esculin negative: Viridans

Front 34

Enterococcus spp
Ampicillin Resistant
Vanco Sensitive

Back 34

Enterococcus faecium non-VRE

Front 35

Enterococcus spp
Ampicillin Vancomycin Resistant

Back 35

Enterococcus faecium VRE

Front 36

Enterococcus spp
Ampicillin, Vancomycin susceptible

Back 36

Enterococcus faecalis

Front 37

Enterococcus spp
Quad plate

Back 37

Test for synergy of aminoglycosides with vancomycin for Enterococci causing bacterial endocarditis

Front 38

Urease test, gram and tissue, name organism

Back 38

Brucella melitensis

Castaneda biphasic blood culture held for 21 days historically used for culture

Front 39

Common-antigen test (glutamate
dehydrogenase or GDH test)

Back 39

Used as a screening test for C. diff. to decide which
specimens to evaluate using another assay (e.g.,
cytotoxicity assay or toxin EIA)

Front 40

Glucose fermenting
Nitrate to nitrite
Oxidase negative

Possible organisms with this colony type in Mac Conkey

Back 40

Lactose fermenting

E. coli (indole+)
Enterobacter spp. (VP test +, catalase+, citrate+)
Klebsiella spp. (VP test +, non-motile, mucoid colonies)

Front 41

Hektoen enteric agar

Back 41

E. coli

Front 42

Hektoen enteric agar

Back 42

Salmonella spp.

H2S production

Front 43

KIA-TSI

Back 43

E. coli
Enterobacter
Klebsiella
Acid Slant/Acid Butt (A/A)

Shigella
Vibrio
Alkaline Slant/Acid Butt (K/A)


Salmonella
Citrobacter
Proteus
Alkaline Slant/Acid Butt (K/A) + H2S

Pseudomonas
Alkaline Slant/Alkaline Butt (K/K)

Front 44

CIN agar

Back 44

Yersinia enterocolitica

•Septicemia in iron overload syndromes
•Mesenteric adenitis – RLQ pain mimics appendicitis
•Grows well at 4*C (like Listeria)
•CIN agar (Cefsulodin-irgasan-novobiocin)

Front 45

Safety pin morphology

Back 45

Yersinia pestis

Front 46

TBCS agar

Back 46

Vibrio cholerae

Oxidase positive/glucose fermenter
KIA: K/A

TCBS (Sucrose)
Yellow: V. cholerae
Green: V. vulnificus, V. parahaemolyticus

Front 47

Gram, identify organism group

Back 47

Vibrio spp

Front 48

Special BAP medium, at 42°C and @ 5% O2, 10% CO2, 85% nitrogen
• Catalase positive
• Oxidase positive

Back 48

Campylobacter spp

• Hippurate hydrolysis test
– If positive, identifies isolate as C. jejuni
– Of Campy species, only jejuni is positive

Front 49

Name organism
Motile

Back 49

E. coli

Front 50

MUG test positive (β-glucuronidase activity)

Back 50

E. coli

Front 51

Name organism
Non-motile
VP+

Back 51

Klebsiella spp

Indole:

+ K. pneumoniae

- K. oxytoca

Front 52

Name organism

Back 52

Proteus spp

Indole:

+ P. vulgaris

- P. mirabilis

Front 53

Name organism
Coagulase -
Novobiocin resistant

Back 53

Staphylococcus saprophyticus

Front 54

Name organism
Thayer Martin
Glucose fermenting

Back 54

Neisseria gonorrheae

Molecular amplification methods
– Permit concurrent detection of CT in single specimen
– Allow use of urine as a specimen (non-invasive)
– Do not require viable organisms (transport not an issue)
– Highly sensitive
– Rapid
• Disadvantages:
– GC DNA may be present up to 3 weeks after successful
treatment, so NAATs should not be used as test of cure
– Isolates not available for susceptibility testing if treatment
difficulties arise
– Results inadmissible evidence in medicolegal cases

Front 55

Blue
Pink
Yellow
Green
Magenta

Back 55

Blue: GBS
Yellow: Listeria monocytogenes
Pink: Pneumococcus
Green: Neisseria meningitidis
Magenta: H. influenzae

Front 56

Name organism

Thayer-Martin
Ferments maltose

Back 56

Neisseria meningitidis

Front 57

Lazy-Beta hemolysis

Back 57

Streptococcus agalactiae

Front 58

Name organism

Back 58

Streptococcus agalactiae

Front 59

Name organism

Back 59

Listeria spp.

Front 60

Name organism

Back 60

Listeria monocytogenes

Front 61

Hyperdiploidy (> 52 chromosomes)

t(12:21)/TEL-AML1 - cryptic, use FISH

Back 61

Favorable cytogenetics for ALL

Front 62

t(9;22) (q34;q11) ABL/BCR (p190)

t(4;11)(q21;23) MLL-AF4

11q23/MLL rearrangments

t(1;19)(q23;p13) PBX/E2A

Hypoploidy < 40 chromosomes

Near tetraploid

Back 62

Unfavorable cytogenetics for ALL

Front 63

t(4;11)(q21;q23) in ALL

Back 63

Expression of CD15 and loss of CD10 (5% of B-ALLs)

Front 64

Inv(16) or t(16;16)(p13;q22)

t(8;21)(q22;q22) AML1/ETO

Back 64

Favorable cytogenetics for AML

Inv(16) or t(16;16)(p13;q22) Core binding factor β and smooth muscle myosin heavy chain

- 10-12% of AML (often younger pts.)
- Myeloid sarcoma may be present at diagnosis
- Myelomonocytic morphology (M4 Eo) with abnormal eosinophils (basophilic granules)
- Auer rods in some cases
- AT LEAST 3% of blasts positive for MPO
- Blasts often at the 20% threshold
- May coexpress CD2


t(8;21)(q22;q22) AML1/ETO (core binding factor)

- May present as granulocytic sarcoma
- Large blasts with abundant cytoplasm
- Pseudo-Chediak-Higashi granules, Auer rods
- “AML with maturation” (may have mono diff)
- Aberrant coexpression of CD19, maybe CD56

Front 65

t(15;17)(q22;q21)

+8

t(9;11) (children)

t(6;9)

Back 65

Intermediate cytogenetics for AML

AML with t(15;17)(q22;q12)

- Acute promyelocytic leukemia (typical and microgranular forms)
- Associated with DIC; microgranular – high WBC count; typical – low count
- Nuclei of blasts often reniform or bilobed
- Numerous Auer rods
- MPO is VERY strong in both forms (why?)
- CD34 and HLA-DR often negative; CD33 bright, may have CD2 coexpression
- Response to ATRA and induction chemo good except in t(11;17)(q23;q21) and t(5;17)

Front 66

- 7

- 5

del 7q

11q23 MLL rearrangements

inv(3q)

Complex abnormalities

Back 66

Bad cytogenetics for AML

Front 67

Back 67

MPO in myeloid blasts

Front 68

Back 68

MPO in myeloid blasts

Front 69

Back 69

PAS in erythroid blasts

Front 70

Back 70

"Apple core" nuclei of APML

Front 71

Back 71

APML in BM

• t(15;17) – RARα and PML
– All-trans retinoic acid (ATRA) responsive
– t(11;17) and t(5;17) – less responsive

Front 72

Back 72

PAS in ALL

Front 73

Normal karyotype

-Y

isolated 5q-

Back 73

Good cytogenetics for MDS

Front 74

20q-

+8

Back 74

Intermediate cytogenetics for MDS

Front 75

Complex karyotype

5q- associated with any other abnormality

17p abnormality

loss of 7

Back 75

Bad cytogenetics for MDS

Front 76

Non-specific esterase (NSE)

ANB (alpha napthyl butyrate)

Back 76

Diffuse cytoplasmic positivity in monoblasts

Front 77

ANA (alpha napthyl acetate)

Back 77

Similar reactivity in monoblasts, but inhibited by sodium fluoride (NaF) (vs. megs, erythroid)

Front 78

Back 78

Hematogones on flow cytometry

Front 79

Extra Philadelphia chromosome

trisomy 8

isochromosome 17q

trisomy 19

Back 79

CML Clonal progression

Front 80

Back 80

Rouleaux with background staining

high-protein states, reactive or clonal

Front 81

Back 81

Agglutination (100
oil)

cold agglutinin disease

Front 82

Back 82

Dual population (40
dry).

This could be seen in partially treated/transfused iron deficiency, sideroblastic anemias, and combined B12/iron deficiency. Transfusion

Front 83

Back 83

Spherocytes (100
oil).

Spherocytes can be seen in
hereditary spherocytosis, autoimmune hemolytic anemia, and acute hemolytic transfusion reaction. Microspherocytes, which are even smaller spherocytes, can be seen in Clostridium perfringens infection and in thermal injury (eg, burns).

Front 84

Back 84

Oxidative process (100
oil).

Blister cells are smaller red blood cells that lack a central pallor. The blister appears as a vacuole at the red blood cell surface. A thin rim of cytoplasm appears to enclose this vacuole.
Bite cells are smaller red blood cells that lack a central
pallor and appear to have an oval bite taken out of the red blood cell. Some cells have more than 1 bite per cell.
Bite blister, and irregularly contracted red blood cells can be seen in oxidative hemolysis (eg, G6PD deficiency) and unstable hemoglobinopathies.

Front 85

Back 85

Fragments (100
oil).smaller red blood cells that lack central pallor.
They are jagged in shape and appear as a piece of red blood cells.
Note how an occasional spherocyte is seen (indicated by the dotted arrows) and a rare, irregularly contracted RBC (indicated by the
thick arrow) is seen. In a microangiopathic (fragmenting) process, occasional spherocytes and irregularly contracted cells are seen; however, this does not represent 2 or 3 separate processes because
the fragments are in the majority.

Front 86

Back 86

Echinocytes (100
oil). Also called burr cells

Renal disease, hypophosphatemia, and blood film artifact.

Front 87

Back 87

Acanthocytes (100
oil). Also called spur cells

McCleod syndrome
Movement disorders
Microcytic disorders such as iron deficiency and hemoglobinopathies and in normocytic/macrocytic disorders such as liver disease and hyposplenic states.

Front 88

Back 88

Eliptocytes (100
oil).

Hereditary eliptocytosis, hemoglobinopathies,
and iron deficiency.

Front 89

Back 89

Hyposplenic changes (100
oil).
The solid arrow is demonstrating a Howell–Jolly body, which is a single, round, smooth, dark blue inclusion body seen in this red blood cell. It represents DNA. The dotted arrow indicates Paphenheimer bodies,
which are multiple, jagged and irregular, light blue inclusion
bodies seen in this red blood cell. It represents iron deposition.
Both these inclusion bodies can be seen in hyposplenic states.

Front 90

Back 90

Basophilic stippling (100
oil).

Basophilic stippling (RNA) seen in thalassemic states, hemolytic processes, and dysplasia. More coarse basophilic stippling has been described in lead poisoning.

Front 91

Back 91

Falciparum malaria (100
oil).

Front 92

Back 92

Pelgerized neutrophil (100
oil). The neutrophil on
the left (indicated by the solid arrow) is hypolobulated and has a mononuclear form. This is considered pelgerized. The neutrophil on the right (indicated by the dotted arrow) is normal.
It can be seen in myelodysplastic disorders or congential disorders

Front 93

Back 93

Toxic changes (100
oil). The neutrophils on this
film demonstrate increased dark red––purple granulation, consistent with toxic granulation.

Front 94

Back 94

Megaloblastic changes (100
oil). A hypersegmented
neutrophil with greater than 6 nuclear segments is seen

Front 95

Back 95

Various platelet sizes and morphologies (100
oil).
The solid arrow indicates a giant hypogranular platelet. The dotted arrow indicates a giant granular platelet. Giant platelets are larger than the size of a normal red blood cell.

Front 96

Back 96

Circulating plasma cells (100
oil). Note the rouleaux formation in the red blood cells.

Front 97

Back 97

Cryoglobulinemia (100
oil). Cloud-like pale purple
cryoglobulin deposits are seen in between and overlaying the red blood cells. When the cryoglobulins overlay the red blood cells, they can give the false appearance of irregularly contracted and bite cells, especially if the cryoglobulins are small and not darkly stained.

Front 98

Back 98

May-Hegglin anomaly, showing Döhle-like inclusions (×1000).

Front 99

Back 99

The Alder-Reilly anomaly may be found in healthy individuals or in those with mucopolysaccharidoses, in which granules are metachromatic (×1000).

Front 100

Back 100

Chédiak-Higashi neutrophils and lymphocytes with large granules

Front 101

Back 101

Inherited Pelger-Huët anomaly (×1000).

Front 102

del(13q14.3)

Back 102

Good cytogenetics for CLL/SLL

Front 103

trisomy 12

del(11q22-23)

del(17q)(TP53)

Back 103

Bad cytogenetics for CLL/SLL

Front 104

Diffuse infiltrate of the BM

Increased proportion of prolymphocytes (between 10% and 55%)

CD38 (> 30% of cells) and ZAP-70

Unmutated IgVH gene

Back 104

Bad prognostic features SLL/CLL

Front 105

Back 105

MCL

t(11;14)(14q32)(11q13) IGH-CCND1

Front 106

Blastoid variant/pleomorphic variant

+ 12

+ 3q

-9q

Complex karyotype

p53 mutations

Back 106

Bad prognostic features for MCL

Front 107

Back 107

MCL in BM: non-paratrabecular infiltrates with histiocytes

Front 108

Back 108

FL t(14;18)(p32)(q21) IGJH-BCL2

Grading:

Centroblasts:

I: 0-15 per HPF
II: 5-15 per HPF
IIIa: >15 per HPF
IIIb: Sheets of centroblasts

Front 109

Back 109

FL in PBS

Front 110

Back 110

Paratrabecular deposits of FL in BM

Also seen in T-cell rich B-cell lymphoma

Front 111

Back 111

- t(11;18) – stomach, lung

– t(1;14) – ocular, parotid, cutaneous

– t(3;14) – ocular, thyroid, cutaneous

– t(1;14) – lung, small bowel

+3 +18 All MZL

Front 112

Back 112

SLVL
•Moderate quantity of cytoplasm
•Polar villi
•Nucleoli

CD19+, CD20+, sIg+, CD11c+
but unlike HCL:
CD103 neg (usually), annexin A1 neg

Front 113

Back 113

HCL
• Cytopenia: neutropenia, monocytopenia
• Immunophenotype
– CD19+, CD20+, sIg+,
– CD11c+ (very bright), CD25+, CD103+, Annexin A1+
– Bcl‐1+
• TRAP+

Front 114

Back 114

BM in HCL:

- Dry tap (increased fibrosis)
- Stripped nuclei
- Blood lake formation

Front 115

Back 115

PEL

- HHV-8+
– Like KS and Multicentric Castleman’s
• HIV +
• Effusion contains large cells with
– Immunoblastic, plasmablastic, anaplastic features
C t l i li ti
HHV8
– Cytoplasmic vacuolization
• Neg for B-cell, T-cell, myeloid antigens
• Pos for CD45, CD30, CD38, CD138, EMA
• Clonal Ig rearrangement +

Front 116

Back 116

BL

Immunophenotype
– CD19+, CD20+, sIg+, CD10+, BCL6+,
– CD34 neg, TdT neg, BCL2 neg

Front 117

Back 117

t(8;14)

t(2;8)

t(8;22)

– Always involving C-MYC (8)

Front 118

Back 118

MM

Three prognostic groups

– Shortest survival – t(4;14), t(14;16), or del(17p)

– Intermediate survival – 13q14 deletions alone

– Longest survival – no anomalies or only t(11;14)

Front 119

Back 119

Essential Thrombocythemia (ET)

• Bimodal, female > male
• Most stable MPD
• Minimal splenomegaly
• Marrow
– Hypercellular
– Large, hyperlobated megakaryocytes
– Clustered, paratrabecular megakaryocytes
• Cytogenetics
– Abnormal in <10%

Front 120

Back 120

PF

• Cellular (prefibrotic) phase
– Marrow hypercellular with increased
megs
– Abnormal megs – appearance and
location
• Fibrotic phase
– Leukoerythroblastic pattern
– Intrasinusoidal hematopoiesis
• Cytogenetics
– 50% abnormal: del(20q), del(13q),
+8, +9

Front 121

Back 121

MPO+SBB:

Granulocytic maturation
– M1, M2, M3, M4
N t MPOd d
MPO SBB
• Note: MPO degrades
quickly in wet specimens

NSE+NSE NaF

Monocytic maturation
– M4, M5
• Sodium fluoride (NaF)
inhibition specific for
monocytic cells

Front 122

Back 122

APML – microgranular variant

Front 123

Back 123

• Autosomal dominant
• Giant platelets, thrombocytopenia, Döhle-like inclusions
• Related to: Fechtner, Sebastian, and Epstein syndromes
• Chromosome 22q12-13 (MYH9 gene – myosin)

May-Hegglin anomaly

Front 124

Back 124

• Most cases seen in children,
median age 2 years
• History of developmental delay
or ophthalmic conditions
• Most common:
– Neuronal ceroid lipofuscinosis (Batten
disease)
– Acid maltase deficiency (Pompe
disease)
– Tay Sachs

Vacuolated lymphs

Front 125

Back 125

Gauchers syndrome

Glucocerebroside deficiency

Front 126

Back 126

E. vermicularis eggs

Front 127

Back 127

Trichuris ovum

Front 128

Back 128

Fertilized Ascaris egg (L)

Unfertilized Ascaris egg (R)

Front 129

Back 129

Hookworm egg

Front 130

Back 130

Hookworm rhabditiform larva

Front 131

Back 131

Strongyloides rhabditiform larva

Front 132

Back 132

Capillaria philippinensis ovum

Front 133

Back 133

• All stages seen (early ring forms to gametocytes)
• RBCs enlarged (trophozoites and later stages)
• As RBC enlarges, membrane remains smooth
• Schuffner’s stippling in intermediate forms
• Schizonts: >12 merozoites
• Gametocyte fills most or all of host cell
• Cycle: 48 hours

P. vivax

Front 134

Back 134

• All stages seen (early ring forms to gametocytes)
• RBCs enlarged (trophozoites and later stages)
• As RBC enlarges, membrane shows projections
• Schuffner’s stippling in intermediate forms
• Schizonts: ≤12 merozoites
• Gametocyte does not fill entire host cell
• Cycle: 48 hours

P. ovale

Front 135

Back 135

P. falciparum, thick smear

Front 136

Back 136

P. falciparum, thin smear

Front 137

Back 137

P. falciparum, gametocyte

• Heavy parasitemia
• Only early ring forms and gametocytes are seen
• Few if any schizonts or trophozoites
• Rings: double chromatin dots common (“headphones”)
• Marginal rings common (applique cells)
• RBCs not enlarged
• No Schuffner’s stippling
• Banana-shaped gametocytes
• Cycle: 36-48 hours

Front 138

Back 138

• Mostly mature forms seen (trophs, schizonts and
gametocytes)
• Few ring forms
• RBCs not enlarged
• No Schuffner’s stippling
• Trophozoites can appear as “band forms”
• Schizonts: 6−12 merozoites
• Cycle: 72 hours

P. malariae

Front 139

Back 139

Babesia, tetrad

Front 140

Back 140

The banana-shaped
gametocyte is diagnostic
if seen.
• Early rings, no trophs
– Applique’ forms
– Dual infected cells
– Dual chromatin dots

P. falciparum

Front 141

Back 141

• Infected large,
young RBCs
– And also causes
enlargement
– BIG RBCs.
• Amoeboid
trophozoites
• Schuffner’s granules
• 12-20 merozoites/
schizont

P. vivax

Front 142

Back 142

• Infects old, small RBCs.
• Heavy, blocky trophs
• ‘Band forms
• 8-12 merozoites/ schizont
• Heavy malarial pigment
• ‘Rosette’ forms

P. malariae

Front 143

Back 143

W. bancrofti

Sheathed
Vector: Mosquito
Nocturnal

Front 144

Back 144

Loa loa

Sheathed
Vector: Mango fly (Chrysops)
Diurnal

Front 145

Back 145

O. volvulus

Unsheathed, from skin,
not blood
Vector: Black fly (Similium)

Front 146

Back 146

H. nana egg, iodine wet prep

Front 147

Back 147

Hymenolepis diminuta (rat tapeworm) eggs

• Size: 70-85 μm X 60-80 μm (larger than H. nana)
• Smooth shell, thicker than H. nana egg shell
• Shell is often yellow to brown in color
• Onchosphere (embryo) inside shell
• No polar thickenings on embryo membrane
• No filaments

Front 148

Back 148

D. latum egg, iodine wet prep

Front 149

Back 149

Sparganosis

Spirometra spp.

Front 150

Back 150

S. mansoni egg, saline wet prep

Front 151

Back 151

S. japonicum egg

Front 152

Back 152

S. haematobium egg with hatching miracidium

Front 153

Back 153

• Hermaphrodite worms
• Morphologically similar
ova
• 130-159 um long
• Small operculum, may
pop open when cover
slip pressed

Fasciola & Fasciolopsis

Front 154

Back 154

Clonorchis/Opisthorchis egg, iodine wet prep

Front 155

Back 155

adult flukes
overall resemble
coffee beans, may
live 10-20 years
• Eggs found in
feces or sputum
– Prominent
operculum
– 68-118 um long

Paragonimus spp.

Front 156

Back 156

• Does not form cysts
• Size: 9-12 μm
• Trophozoite has 2 nuclei
• No observable flagella, but classified as a flagellate
• Moves by means of pseudopodia when seen in feces
• Fairly strong association between Enterobius vermicularis
and D. fragilis infections has been noted—suggesting that
D. fragilis may sometimes be transmitted via pinworm
eggs

Dientamoeba fragilis

Front 157

Back 157

• Detection of oocysts in stool
• Modified acid fast stain of concentrated
stool specimen
• Football shaped (oval with tapered ends)
• Size: 20-33 μm long X 10-19 μm wide
• Single sporoblast inside
• Color: Red (MAF stain)

Isospora belli

Front 158

Back 158

Cyclospora and Cryptosporidium oocysts, MAF stain

Detection of oocysts in stool
• Modified acid fast stain of concentrated
stool specimen
• Shape: Spherical
• Size: 8-10 μm (twice the size of
Cryptosporidium oocysts)
• Color: Red (MAF stain)

Cyclospora cayetanensis

Front 159

Back 159

Microsporidial spores in stool, modified trichrome stain

• Histology: PAS, GMS, acid-fast stains highlight
organisms in tissue biopsy
• Modified trichrome-stained fecal smears can
reveal spores
• Characteristic orange-red color on modified
trichrome stain
• Size: 1-2 μm
• Shape: round
• Red “band” or dot is often present

Microsporidia spp

Front 160

Back 160

Eggs are 60-75 m in
length and 40-50 m
wide
– Operculum, sometimes
difficult to visualize
– Small knob on the
abopercular end, may
or may not be evident;
sometimes only a
roughening or
thickening of the egg
wall

Diphyllobothrium latum

Front 161

Back 161

• T. solium: 7-13 uterine branches
• T. saginata: 15-30 branches

• Beef tapeworm -- T. saginata
– sub-Saharan Africa, the Balkans and Middle
East, Latin America, and Russia
– 77 million infected
• Pork tapeworm -- T. solium
– Latin America (especially Mexico), Africa,
southeast Asia, and eastern Europe
– 10 million infected

Front 162

Back 162

HSV infected cell monolayer Rounded cells on edge of monolayer Rapid cell killing

Front 163

Back 163

VZV
infected monolayer Foci of sandpaper CPE with rounded cells

Front 164

Back 164

CMV infected monolayer Focal grape like cluster of rounded cells

Front 165

Back 165

EBV Serodiagnosis
Heterophile antibodies (HA) react with antigens phylogenetically unrelated to the antigenic determinants against which they were raised
HA secondary to EBV are detected by their ability to react with horse or cattle rbc’s. (Monospot test)
Rise in the first 2 - 3 weeks of EBV infection, then rapidly fall at @ 4 weeks
Cannot be used in children < 4 years of age

Front 166

Back 166

Adenovirus CPE – rounded cells Connected by strands

Front 167

Back 167

CPE of Enterovirus Teardrop and kite like cells

Front 168

Back 168

Classic CPE = Syncytium formation Respiratory syncytial virus CPE

Front 169

Back 169

Ziehl-Neelsen smear from broth culture, M. tuberculosis

Cording factor

Front 170

MTB: Susceptibility Testing
• Rapid method
– Broth culture using single “critical concentration” for
each drug
– Streptomycin, INH, rifampin, ethambutol, PZA
• Standard method
– Agar proportion
– Also uses critical concentrations, but other
concentrations sometimes added
– Expanded panel of drugs can be tested

Back 170

MDR and XDR TB
• MDR TB: TB isolate that is
resistant to both isoniazid and
rifampin
• XDR TB: MDR + resistance to
fluoroquinolone and 1 of the 3
injectable drugs (amikacin,
kanamycin, capreomycin)

Front 171

, shielded , exposed (R)

Back 171

M. kansasii, shielded (L)
M. kansasii, exposed (R)

Front 172

exposed

Back 172

• Slow growth
• Temperature preference = 37°C
• Thin, long, branching, acid-fast rods on smear from liquid
culture
• Usually nonchromogenic; some isolates can be pigmented
• Identification by DNA probe from culture
– All 3 MAC species are recognized by the commercial DNA probe
for MAC (Accuprobe by GenProbe, San Diego); does not
differentiate between species
– Specific probes for M. avium and M. intracellulare exist; MAC-X
is negative by both

M. avium complex

Front 173

exposed

Back 173

• Found in hot water systems—optimum growth
temperature is 42°C
• May take 6 weeks or longer to grow because 37°C
incubation is not optimal
• Causes chronic pulmonary disease in adults with
underlying disease (e.g. COPD or bronchiectasis)
• Extrapulmonary infection seen only in
immunocompromised

• Slow growth
• Optimum growth at 42°C
• Long, thin, branching, acid-fast rods on
smear from liquid culture (“atypical
morphology”)
• Scotochromogenic
• Identified biochemically

M. xenopi

Front 174

, shielded , exposed (R)

Back 174

• Causes cutaneous infection
• Associated with exposure to freshwater fish
tanks or saltwater following trauma
• “Fish tank granuloma”—single nodular
lesion confined to one extremity
• Appears 2-3 weeks after inoculation
• In US, most common in southern coastal
states

• Classified as a slow grower, but some strains
manifest rapid growth
• Primary isolation requires incubation at 30°C
• Thin, long, branching, acid-fast rods on smear
from liquid culture (“atypical” morphology)
• Photochromogenic
• Identified biochemically

M. marinum

Front 175

Back 175

• Most commonly recovered non-pathogenic
NTM
• Non-pathogenic even in
immunocompromised patients
• Widely distributed in soil and water
• Frequently contaminates respiratory
specimens sent for mycobacterial culture

M. gordonae

Front 176

Rapid Growers

• All are 3-day arylsulfatase positive
• All grow on MacConkey agar lacking
crystal violet
• Differentiated using 3 biochemical tests:
iron uptake, salt tolerance, and nitrate
reduction

Back 176

M. fortuitum group
• Positive iron uptake
• Tolerant to 5% NaCl (heavy growth)
• Positive nitrate reductase
• Resistant to all standard anti-TB drugs
• Many drug options, including amikacin, cefoxitin,
quinolones (ciprofloxacin, gatifloxacin,
moxifloxacin), clarithromycin, doxycycline,
sulfonamides, imipenem)
• Drug combinations are recommended

M. chelonae: Features
• Negative iron uptake
• Not tolerant to 5% NaCl (minimal growth)
• Negative nitrate reductase
• Resistant to all standard anti-TB drugs
• Fewer drug options than M. fortuitum
– Susceptible to amikacin, imipenem, tobramycin,
clarithromycin
– Resistant to fluoroquinolones, cefoxitin
• Clarithromycin is the drug of choice for localized
infections

M. abscessus: Features
• Negative iron uptake
• Tolerant to 5% NaCl (heavy growth)
• Negative nitrate reductase
• Resistant to all standard anti-TB drugs
• Fewer drug options than M. fortuitum
– Susceptible to amikacin, cefoxitin, imipenem,
clarithromycin
– Resistant to fluoroquinolones
• Clarithromycin is the drug of choice for localized
infections, although resistant strains are emerging

Front 177

Back 177

Plate morphology
– Cream/white colored, smooth, large colonies
– Colonies on BAP show mycelial projections into the agar, called “feet” or
“star-like”

Candida albicans

Front 178

Back 178

Microscopic morphology
– In primary smears, relatively large (3-6 μm) budding yeast with
pseudohyphae (and sometimes true hyphae)
– When grown on morphology medium:
• Pseudohyphae with clusters of blastoconidia at the septations
• Single terminal chlamydospores (large, thick-walled)
• Some true hyphae may be seen as well
• Positive by germ-tube test within three hours
• Smooth green colonies on Candida Chromagar plate
• Detection of β-D-galactoaminidase activity

Candida albicans

Front 179

Back 179

• Plate morphology
– Small colonies, smooth, glistening
– White to cream colored

Candida glabrata

Front 180

Back 180

• Microscopic morphology
– In primary smears, small ( 2-5 μm) budding yeast
without pseudohyphae or true hyphae
– When grown on morphology medium:
• Budding blastospores
• No other structures
• Positive by rapid assimilation of trehalose test
(RAT assay)

Candida glabrata

Front 181

Antifungal Susceptibility
Candida spp

Back 181

• Candida albicans is generally sensitive to azoles and other
antifungals
• 10% of Candida glabrata isolates are azole resistant
• Another 20-30% have reduced azole susceptibility
• C. krusei is intrinsically resistant to fluconazole
• C. lusitaniae is considered resistant to amphotericin
(despite low MICs in many cases)
• C. parapsilosis, C. krusei, C. guilliermondii and C.
lusitaniae sometimes exhibit relatively high caspofungin
MICs but most are probably susceptible

Front 182

Antigen Detection: Specificity

Cryptococcus neoformans

Back 182

• Very few false-positive results, when
performed properly
• Cause of false positives:
– Trichosporon beigelii infection (cross-reactive
polysaccharide is produced)
– Contamination with agar and syneresis fluid on
agar
– Platinum wire loops

Front 183

Antigen Detection: Sensitivity

Cryptococcus neoformans

Back 183

• Varies by population, stage or duration of
infection, and assay methodology
• In general, highly sensitive (~99%)
• At least as sensitive as culture
• Most false-negative results are due to extent of
infection
– Single focal lesions, e.g., pulmonary lesions, may not
produce a great quantity of antigen
– False negatives are less frequent in disseminated or
progressive pulmonary infections, but do occur

Front 184

Back 184

C. neoformans on BAP

• Positive for urease activity
• Positive phenol oxidase test
– Detects ability of yeast to produce phenol oxidase on
substrates containing caffeic acid
– Most frequently used medium is birdseed agar
– C. neoformans turns dark brown in 2-5 days; other
cryptococcal species do not
• Identified biochemically using commercial
platforms (e.g. VITEK yeast card)

Front 185

Back 185

A. fumigatus

Front 186

Back 186

Aspergillus in Tissue (H&E Stain)

Arborescent growth, thin hyphae, 45 degree angle dichotomous branching

Front 187

Back 187

A. fumigatus

Single row of phialides

Front 188

Back 188

A. flavus

Front 189

Back 189

A. flavus

Circumferential phialides

Front 190

Back 190

A. niger

Front 191

Back 191

A. niger

Heavily pigmented

Front 192

Back 192

A. terreus

Front 193

Back 193

A. terreus

Two rows of phialides

Front 194

Back 194

Penicillium spp

Front 195

Back 195

Penicillium spp

Front 196

Back 196

Fusarium spp

Front 197

Back 197

Fusarium spp

Canoe-shaped/Banana boat

Associated
with Bone marrow transplant
and corneal infections

Front 198

Back 198

T. rubrum

Front 199

Back 199

T. rubrum

Trichophyton
rubrum
Rare Pencil shaped macroconidia
Many microconidia

Front 200

Back 200

Microsporum canis

Rate of growth: moderate; mature within 6-10
days
• Colony morphology: Surface is white and fluffy;
reverse is lemon yellow to yellow-brown

Front 201

Back 201

Microscopic morphology: Septate hyphae with
long, spindle-shaped, rough (echinulate)
macroconidia which taper to a knob-like end; few
if any microconidia
• Macroconidia contain >6 cells

Microsporum canis

Front 202

Back 202

Epidermophyton floccosum

• Rate of growth: moderate; mature within 10 days
• Colony morphology: surface yellow to brown to
olive-gray and velvety; reverse is orange to
brownish

Front 203

Back 203

• Microscopic morphology: septate hyphae, no
microconidia; macroconidia are smooth, clubshaped
with rounded ends, and contain 2-6 cells;
macroconidia found singly or in characteristic
clusters
Beaver tail spores – no microconidia

Epidermophyton floccosum

Front 204

Back 204

Zygomycosis (GMS Stain)

In tissue – 90* angle branching, aseptate, ribbon like

Front 205

18 hours (L)
48 hours (R)

Back 205

Rhizopus spp

Zygomycetes in general

Front 206

Back 206

Rhizopus spp

Front 207

Back 207

Mucor

Front 208

Back 208

Absidia spp

Front 209

Back 209

Penicillium marneffei

Red diffusable pigment
Uncommon dimorphic fungus
Skin lesions in tropics
Pneumonia in immune suppressed

Front 210

Back 210

Scopulariopsis species

Front 211

Back 211

Paecilomyces species

Front 212

Back 212

Trichophyton tonsurans

Epidemic Scalp ring worm
Ballooning microconida

Front 213

Back 213

Microsporum gypseum - soil

Front 214

Back 214

Trichophyton rubrum

Pencil shaped macroconidia
Many microconidia

Front 215

Back 215

Microsporum canis

Dog and cat ringworm
White colony/ yellow reverse
Tuberculate macroconidia –
With very few microconidia

Front 216

Back 216

Malassezia furfur
 Lipophilic yeast – oil required for growth
 Media used for culture must oil or oil overlay
 Small budding yeast 2 – 4 μM with collarette

Front 217

Back 217

Exophila spp, mature and early yeast-like

Black Molds that cause
Mycetoma/Chromomycosis/Phaehypho

Front 218

young yeast-like colonies

older fuzzy colonies

Back 218

Exophila spp.

Black Molds that cause
Mycetoma/Chromomycosis/Phaehypho

Front 219

Back 219

Cladophialophora bantiana

Black Molds that cause
Mycetoma/Chromomycosis/Phaehypho

Front 220

Back 220

Wangiella species

Front 221

Back 221

Phialophora species

Front 222

Back 222

Alternaria spp.

Front 223

Back 223

Alternaria spp.

Front 224

Back 224

Bipolaris species

Very invasive
Skin, nasal sinuses, bone brain

Front 225

Back 225

Curvularia species

Front 226

Back 226

Scedosporium apiospermum/
Pseudallescheria boydii

Front 227

Back 227

Exserohilum species

Steroid injections
CSF infections

Front 228

Back 228

Pseudallescheria boydii
• The name “P. boydii” refers to the sexual
state of the fungus
• P. boydii is the telemorph of Scedosporium
apiospermum and Graphium eumorphum
(asexual forms)

Front 229

Back 229

Scedosporium apiospermum

P. boydii

Graphium

Front 230

cycloheximide agar (L)

Back 230

Scedosporium prolificans,

Front 231

Back 231

Scedosporium prolificans,

Front 232

Back 232

- Grows as a mold at 25°C, grows as a yeast form at 37°C
• Plate morphology:
– Slowly growing, fluffy white colonies initially; buff or brown with age
– Yellow to yellow-brown reverse

• Conversion of the mold to the yeast form at 37°C
• Demonstration of specific precipitins by
exoantigen testing

Histoplasma capsulatum

Front 233

mold form

yeast form

Back 233

• Microscopic morphology:
– Large, rounded, single-celled, tuberculate (rough walled)
macroconidia on short conidiophores
– Pyriform microconidia; may be sessile on the sides of hyphae or on
short conidiophores

Histoplasma capsulatum

Front 234

Back 234

Tuberculate [projections]
Macroconidia And Microconidia

Histoplasma capsulatum

Front 235

Back 235

Sepedonium species

Looks like Histoplasma grows in 5 days/monomorphic
Large rough spores (7 – 17 um),
usually saprophyte
No micro-conida are formed

Front 236

Back 236

H. capsulatum var duboisii

Found in Central Africa
Associated with skin and bone lesions
30˚C culture identical to H capsulatum
Yeast cells 8 – 10 um in size 2X the size of regular Histoplasma

Front 237

Back 237

Blastomyces Culture at 37*C
Slow growing @ 4 weeks

Front 238

Culture at 30˚C (L)
Culture at 37*C (R)

Back 238

Blastomyces dermatitidis

Culture at 30˚C (L)
Pear shaped conidia like lollipops
Look alike fungus – Chrysosporium species
Do DNA probe to confirm identification

Culture at 37*C (R)
Yeast cell is 8 – 20 um in size

Front 239

Back 239

Culture at 30˚C
 Requires 2 – 3 days to grow, white waxy / wooly

Coccidioides immitis

Front 240

Back 240

Septated hyphae with chains of thick walled barrel
shaped arthroconidia with dead cells in between –
arthroconidia inhaled in nature

in culture from media
incubated at both 30* and 35*C – No yeast phase

Coccidioides immitis

Malbranchea species is look alike fungus

Front 241

Back 241

Thick walled spherules (10 – 80 uM) with
endospores NO YEAST CELLS
 All stages of development / fragmented spherules
 Granulomatous inflammation with caseation

Coccidioides immitis

Front 242

Back 242

Rhinosporidium seeberi spherules - > 80 uM
Larger than Coccidioides spherules

Front 243

Back 243

Culture @ 37˚C
 Slow (3- 4 weeks) waxy coral-like yeast
 Large yeast (10 – 30uM) with multiple daughter
buds (2 – 10 uM)

Paracoccidioides brasiliensis

Front 244

Young (L)
Old (R)

Back 244

MOLD PHASE
 30*˚C growth in 3 -5 days
 Turns brown to black over time

Sporothrix schenckii

Front 245

Back 245

MOLD FORM (30 C)
Septate hyphae with conidia in daisy wheel
pattern

Sporothrix schenckii

Front 246

Back 246

YEAST PHASE

At 37˚C small oval yeast cells, elongated 2 – 5 μM, described as cigar bodies

Sporothrix schenckii

Front 247

Back 247

Sporothrix schenckii

Asteroid body known as Splendore-Hoeppli phenomenon can be seen – also seen in:
 Zygomycetes (mucorales)
 Aspergillus
 Blastomycosis
 Candida

Front 248

Back 248

Penicillium marneffei

Front 249

Back 249

Brown colonies on Birdseed agar

C. neoformans

Front 250

Back 250

Cryptococcus gatti

In culture and staining identical to C.
neoformans except for L Canavanine glycine
bromthymol blue medium – C. gatti = blue
C.neoformans = colorless

Front 251

Back 251

Paroxysmal cold hemoglobinuria, with erythrophagocytosis; the arrow points to a red cell that has been phagocytosed by a neutrophil.

Front 252

Back 252

Macrocytic anemia resulting from congenital dyserythropoietic anemia type 1 also yields a characteristic blood smear, with striking poikilocytosis

CDA type I is transmitted by both parents autosomal recessively and usually results from mutations in the CDAN1 gene.

CDA type I is characterized by moderate to severe anemia. It is usually diagnosed in childhood or adolescence, although in some cases, the condition can be detected before birth. Many affected individuals have yellowing of the skin and eyes (jaundice) and an enlarged liver and spleen (hepatosplenomegaly). This condition also causes the body to absorb too much iron, which builds up and can damage tissues and organs. In particular, iron overload can lead to an abnormal heart rhythm (arrhythmia), congestive heart failure, diabetes, and chronic liver disease (cirrhosis). Rarely, people with CDA type I are born with skeletal abnormalities, most often involving the fingers and/or toes

Front 253

Back 253

Erythrocyte with prominent basophilic stippling (arrow), a result of lead poisoning

Front 254

Back 254

Burkitt’s lymphoma, with three basophilic vacuolated lymphoma cells

Front 255

Back 255

Hypogranular promyelocytic leukemia is shown in Panel B, with two characteristic bilobed leukemic promyelocytes

Front 256

Back 256

Cryoglobulin deposition in a blood sample from a patient with hepatitis C virus infection

Front 257

Back 257

HbC - clams

Front 258

Back 258

HEINZ BODY

require supravital dye
- crystal violet (reticulocyte stain)

• causes:
- denatured/oxidized Hb
- G6PD deficiency
- unstable hemoglobins
• bite cells have had them bitten out