Mr.

X has been shot by a gun on his leg and he developed gas gangrene and he
was told that he should be amputated .samples from the wound revealed a
gram positive anaerobic organism. What is the most likely organism found in
the sample taken?
Ans= Clostridum Perfinges

Case=Gas gangrene
 What is gas gangrene?

o Progressive gangrene marked by impregnation of the dead and dying

tissue with gas which is caused by one or more toxin producing
bacteria of the genus clostridum that enters the body through wound
and proliferate in necrotic tissue.
 Where does the gas comes from?

o metabolic activity of the rapidly dividing bacteria

 What is the etiology of gas gangrene?

o Clostridum perfinges= the most common

o Clostridum septicum
o Clostridum histolyticum
 What other diseases can clostridum perfinges cause?

o Soft-tissue infections (e.g., cellulitis, suppurative myositis, food poisoning,

enteritis necroticans,
 What other common clostridium species do you know?

o C. diffiile = Antibiotic-associated diarrhea,pseudomembranous colitis

o C. botulinum = Botulism
o C. tetani= tetanus
 What is the general feature of all clostridium species?

(1) presence of endospores,

(2) strict anaerobic metabolism,
(3) gram-positive cell wall structure
(4) The organisms are ubiquitous in soil, water, and sewage and are
part of the normal microbial flora in the gastrointestinal tracts of
animals and humans.
(5) Most clostridia are harmless saprophytes, but some are well-
recognized human pathogens
 Which clostridium species are motile?

o All clostridium species are motile except C. perfinges

 How does clostridum perfinges cause gas gangrene?
o It produces toxin and enzymes that has the potential to cause tissue
destruction , hemolysis , increase vascular permeability and end up in
necrosis.
 How does clostridum perfinges cause enterocolits and end up with

watery diarrhea?
o Produces a heat-sensitive enterotoxin that binds to receptors on the
epithelium of the small intestine, leading to loss of fluids and ions (watery
diarrhea).
 Describe the type of spores each organism produce?

o C. tetani = terminal & round spores

o C. botulinum = sub-terminal & oval spores
o C. difficle = sub-terminal & oval spores
 Describe the virulence factors of the common clostrium species?

o C. Perfinges = toxins and enzymes

o C. Tetani = tetanospasmin
o C. Botulinum= botulium toxin
o C. Difficle= toxins

 What is tetanospasmin?

o a heat labile neurotoxin that blocks release of neurotransmitters (i.e.,

gamma-aminobutyric acid, glycine) for inhibitory synapses these
result in inhibition of the inhibitory so the excitatory ones will
dominate resulting in excessive muscle contraction i.e spasm
 what is botulium toxin?

o a toxin that prevents release of the neurotransmitter acetylcholine,

thus blocking neurotransmission at peripheral cholinergic synapses,
leading to a flaccid paralysis

o It causes floppy baby syndrome

 How does c.difficle cause diarrhea?

o it two toxins: an enterotoxin that attracts neutrophils and stimulates

their release of cytokines, and a cytotoxin that increases permeability
of the intestinal wall and subsequent diarrhea
 What is unique for C. tetani among the other types of clostridum?

o It is diagnosed clinically as microscopy and culture can’t detect it.

 What are the major types of botulism?

o Infant botulism
o Wound botulism
o Foodborne botulism
 Describe about foodborne botulism?

o It is regarded as intoxication because a preformed toxin in a

canned food is ingested.
o The toxin is absorbed in the GI and enters into the circulation then
reaches to the peripheral neuromuscular synapses.
o It manifests as:
 dizziness and dryness of the mouth.
 Blurred vision, inability to swallow, difficulty in speech,
 weakness of skeletal muscles and respiratory paralysis----death
 Describe about infant botulism?
o It is regarded as ingestion-intoxication because the spore in the
solid foods/honey is first is ingested and then the toxin is produced
invivo (inside the body) and cause the same effect
o It manifests as:
 constipation and weak sucking ability
 generalized weakness
 Describe about wound botulism?
o It is relatively rare.
o develops from toxin production by C. botulinum in contaminated
wounds.
o the incubation period is generally longer (4 days or more),
o the gastrointestinal tract symptoms are less prominent
 Describe gram staining procedure?
o Gram stain is a rapid, powerful, easy test, develop an initial
diagnosis.
 o Bacteria are heat fixed or otherwise dried onto a slide, stained with
crystal violet, a stain that is precipitated with iodine, and then the
unbound and excess stain is removed by washing with the acetone-
based decolorizer and water. A red counterstain, safranin, is added
to stain any decolorized cells. This process takes less than 10
minutes. For gram-positive bacteria, which turn purple, the stain
gets trapped in a thick, cross-linked, mesh like structure, the
peptidoglycan layer, which surrounds the cell. Gram-negative
bacteria have a thin peptidoglycan layer that does not retain the
crystal violet stain; so the cells must be counterstained with safranin
and turned red. A mnemonic device that may help is “P-PURPLE-
POSITIVE.”
 Mention some organisms that can’t be gram stained?
o Mycoplasma
o Mycobacterium
o Chlamydia
 Describe the Acid Fast staining procedure?
o Used to stain mycobacteria and other acid-fast organisms. Organisms
are stained with basic carbolfuchsin and resist decolorization with
acid-alkali solutions. Background is counterstained with methylene
blue.
o Organisms appear red against light-blue background because it
retains the color of the primary dye (carbol fuchsin)
o Example of the bacteria that show these behaviors are
mycobacterium
 What is the difference between the term sensitivity and specificity?
o The sensitivity of a test is the probability that it will be positive in the
presence of a pathogen
o The Specificity is the probability that a test will be negative if the
pathogen is not present
 Why was Mr. X adviced to get amputated?
o Because it has already developed gangrene which is irreversible cell
death.
 What is cell injury?
 o It is an injury to the cell which can end up in transient or permanent
effect of the cell.
o It depends on the type of cell
 Neurons= very sensitive to hypoxia
 Skeletal muscles and skin= least sensitive to hypoxia

 What etiologies of cell injury do you know?

o Hypoxia
o Nutritional deprivation
o Inflammation
o Trauma
o Genetic mutation
 What are the phases of cell injury?
o Early= reversible
 Hall mark is cell swelling
o Late= irreversible
 Hall mark is membrane damage

 What adapations to cell injury do you know?

o Hypertrophy= increase in the size of the cells.
o Hyperplasia= increase in the number of the cells.
o Atrophy= decrease in the size and the number of the cells.
o Metaplasia= change in cell type in response to stress
o Dysplasia= disordered cell growth
o Aplasia= lack of cell growth and production
o Hypoplasia =decrease in cell production during embryogenesis.
 What is the mechanism of cell hypertrophy?
o Increased protein (cytoskeleton) synthesis
o Gene activation
o Production of organelle
 Can all cells undergo hyperplasia?
o NO!!!
o Because some cells are terminally differentiated that is they have no
stem cells
o Examples: skeletal muscle, cardiac muscle, neuron
 o So these cells rather undergo hypertrophy
 Do all hyperplasia progress to cancer?
o NO!!! for example benign hyperplasia of the prostate (BPH) is a type
of hyperplasia but does not lead to cancer
 Give at least two best example of metaplasia?
o In the habitual cigarette smoker, the normal ciliated columnar
epithelial cells of the trachea and bronchi are often replaced focally
or widely by stratified squamous epithelial cells.
o Barret’s esophagus
 Normally the epithelium of the esophagus is stratified
squamous but when there is chronic stress like
GERD(gastrointestinal reflux disease) it can turn out to be
coloumnar epithelium
 It is one of the precursor lesion of adenocarcinoma of the
esophagus
 What are the two carcinomas of the esophagus?
o Squamous cell carcinoma
 Usually due to smoking
 High in developing countries
o Adenocarcinoma
 Usually due to barret’s esophagus
 High in developed countries
 Do all metaplasia lead to cancer?
o NO!!! for example apocrine metaplasia of the breast does not do so.
 What is typical of cell death?
o Loss of nucleus
o Mechanism of loss of nucleus
 Pyknosis = nucleus shrinkage
 Karyorrhexis = nucleus breakage
 Karyolysis= further disintegration
 What is the mechanism of cell death
o Apoptosis
o Necrosis
 Describe them briefly?

Feature Apoptosis Necrosis

Definition Programmed and Cell death along with
coordinated cell death degradation of tissue
by hydrolytic enzymes
Causative agents Physiologic and Always pathologic
pathologic processes
-No Inflammatory Inflammatory
reaction reaction always
-Death of single cells present
Cell shrinkage -Death of many cells
Cytoplasmic blebs Cell swelling initially
Morphology on membrane
Apoptotic bodies Membrane disruption
Chromatin Damaged organelles
condensation
Phagocytosis of Nuclear disruption
apoptotic bodies by
macrophages Phagocytosis of cell
debris by
macrophages

 List the types of necrosis ?

o Coagulative necrosis
o Liquefactive necrosis
o Gangrenous necrosis
o Casesous necrosis
o Fat necrosis
o Fibrinoid necrosis
 What is coagulative necrosis?

o The tissue is dead but the structure of the tissue is still firm due to
the coagulation of the cell protein
 o It is seen in ischemic infarction of any organ except brain
 What is liquefactive necrosis?

o The tissue is dead plus enzymatic lysis of cells and protein which
makes it structure less.
o Seen in brain infarction and pancreatitis
 What is gangrenous necrosis?

o It is coagulative necrosis that resemble mummified tissue.

o It is characteristic of ischemia of the lower limb or the GIT
o If it is not infected it remains dry but if is infected it becomes wet.
 What is fat necrosis?

o Necrosis of the adipose tissue which result in death of the adipocyte

and release of fatty acid which can bind to the calcium to appear
white.
o Example: Fat necrosis of the breast after trauma is a common
phenomenon. It has calcification on x-ray which mimic breast cancer.
o Example: pancreatitis
 What is fibrinoid necrosis?

o It is necrosis of blood vessels that cause leakage of protein into the

blood vessel wall resulting in pink staining
o Examples: malignant hypertension and vasculitis
 What is caseous necrosis?

o Soft, friable necrotic tissue with cottage cheese appearance

o Example: granulomatous inflammation in TB and fungal infection.
 How do we classify antibacterial drugs?

o Cell wall synthesis inhibitors

 Beta lactams= penicillin , cephalosporin , monobactam , carbapenem
 Vancomycin
 Bacitracin
o Protein synthesis inhibiotors
 Aminoglycosides
 Tetracycline
 Chloramphenicol
 Macrolides
 Clindamycin
o Nucleic acid synthesis inhibitors
 Rifampin
 Quinolones
 Fluroquinolones
o Drugs modifying energy metabolism?
 Sulfonamides
 Dapsone
 How do we classify penicllins?

o Natural
o Semi-synthetic
o Broad spectrum
o Extended spectrum
 What are the two natural pencillin?

o Penicillin G
 Acid labile, polar, IV
o Penicillin V
 Acid resistant, non-polar, oral
 Why do we use penicillin G with probenecid?

o To decrease tubular excretion of penicillin G because probenecid

competes then will increase half-life of penicillin G.
 Mention some the semisynthetic penicillin?

o They are beta lactamase resistant unlike the natural ones

o Example= methicillin, cloxacillin, oxacillin…..
 Mention some the broad spectrum penicillin?

o Ampicillin, amoxicillin
o They are beta lactamase sensitive.
o Amoxicillin is the best(100% absorbed)
 Mention some of the extended spectrum penicillin?

o Piperacillin, ticarcillin.
o They are called anti-pseudomonal penicillin
 Describe the generations of cephalosporin?

o 1st generation
 Examples: all of them with “-ph” and cefazolin , cefadroil
o 2nd generation
 Examples: cefotetan , cefuroxime
 Only cefuroxime cross the BBB.
 o 3rd generation
 Example: ceftriaxone(tri means three so third generation)
 They can pass BBB so can be used for meningitis
o 4th generation
 Example: cefepime
o Key point= while going from first to fourth generation activity against
gram negative increase but against gram positive will decrease
 How does a muscle contract?

NM junctions work very much like a synapse b/n neurons:

1. When an AP reaches the axon terminal it causes Ca channels
to open.Ca2+ rushes into the cell because Ca2+ outside is much higher
than Ca2+ inside
2. Ca2+ causes some of the vesicles to fuse with the membrane
and release their Ach.The terminal region is loaded with vesicles
containing the transmitter Ach
3. ACh diffuses across the synaptic cleft binds to the Ach
receptor in the postsynaptic membrane.
4. Binding causes an ion channel to open
5. The flow of ions depolarizes the membrane, producing an
EPP.
6. An AP is generated in the muscle membrane
34

7. The muscle AP causes release of Ca2+ from the SR of the

muscle and this triggers muscle contraction

8. Back in the synapse the ACh is broken down to acetate and

 choline by the enzyme acetyl cholinesterase
9. The choline is recycled. A choline pump returns it back into the
nerve terminal there it is converted back into Ach.
 How does a muscle relax?
o It has the following steps:
 Following muscle contraction, Ca2+ is re-uptaken back into
longitudinal SR by Ca-pump, this requires ATP.Functionally,
the terminal cisternae serve as storage places for calcium
during muscle relaxation and can be released again.
 Decreased Ca2+ in the sarcoplasm→ Ca2+ detaches from
troponin-C →Tropomyosin covers the active sites of actin.
 Head of myosin charged with ATP, and detached from
actin.Therefore, muscle relaxation is an active process
requiring energy.
 Compare and contrast the different muscle types?
 Describe the major intercellular junctions?