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Antigens are separated by electrophoresis into an agar gel that contains antibody anxiety 7 weeks pregnant cheap doxepin online. Antibody is then placed in the trough anxiety symptoms abdominal pain buy doxepin 75 mg amex, and precipitin lines form as antigen and antibody diffuse toward each other. Antigen can be detected by direct assay with antiviral antibody modified covalently with a fluorescent or enzyme probe, or by indirect assay using antiviral antibody and chemically modified antiimmunoglobulin. In direct immunofluorescence, a fluorescent molecule is covalently attached to the antibody. In indirect immunofluorescence, a second fluorescent antibody specific for the primary antibody. A fluorescent molecule or an enzyme attached to the avidin and streptavidin allows detection. These techniques are useful for the analysis of tissue biopsy specimens, blood cells, and tissue culture cells. A laser is used in the flow cytometer to excite the fluorescent antibody attached to the cell and to determine the size and the granularity of the cell by means of lightscattering measurements. The cells flow past the laser at rates of more than 5000 cells per second, and analysis is performed electronically. The data obtained from a flow cytometer are usually presented in the form of a histogram, with the fluorescence intensity on the x-axis and the number of cells on the y-axis, or in the form of a dot plot, in which more than one parameter is compared for each cell. It is quantitated spectrophotometrically according to the optical density of the color produced in response to the enzyme conversion of an appropriate substrate. The actual concentration of specific antibody can be determined by comparison with the reactivity of standard human antibody solutions. In these assays, soluble antigen is captured and concentrated by an immobilized antibody and then detected with a different antibody labeled with the enzyme. In this technique, viral proteins separated by electrophoresis according to their molecular weight or charge are transferred (blotted) onto a filter paper. A, the flow cytometer evaluates individual cell parameters as the cells flow past a laser beam at rates of more than 5000 per second. The antigen-antibody complexes are precipitated and separated from free antibody, and the radioactivity is measured for both fractions. The residual complement is then assayed through the lysis of red blood cells coated with antibody. Antibodies measured by this system generally develop slightly later in an illness than those measured by other techniques. A variation of this test can also be used to identify genetic deficiencies in complement components. Antibody inhibition assays make use of the specificity of an antibody to prevent infection (neutralization) or other activity (hemagglutination inhibition) to identify the strain of the infecting agent, usually a virus, or to quantitate antibody responses to a specific strain of virus. For example, hemagglutination inhibition is used to distinguish different strains of influenza A and the potency of antibody developed by new vaccines for influenza. Latex agglutination is a rapid, technically simple assay for detecting antibody or soluble antigen. Virus-specific antibody causes latex particles coated with viral antigens to clump. Conversely, antibody-coated latex particles are used to detect soluble viral antigen. In passive hemagglutination, antigen-modified erythrocytes are used as indicators instead of latex particles. The antibody type and titer and the identity of the antigenic targets provide serologic data about an infection. Serologic testing is used to identify viruses and other agents that are difficult to isolate and grow in the laboratory or that cause diseases that progress slowly (Box 6-2). The amount of IgM, IgG, IgA, or IgE reactive with antigen can also be evaluated through the use of a labeled second antihuman antibody that is specific for the antibody isotype. Seroconversion occurs when antibody is produced in response to a primary infection. Specific IgM antibody found during the first 2 to 3 weeks of a primary infection is a good indicator of a recent primary infection. Reinfection or recurrence later in life causes an anamnestic (secondary or booster) response. Antibody titers may remain high, however, in patients whose disease recurs frequently.
The immune system has evolved mechanisms to avoid a vigorous immune response to food antigens on the one hand and anxiety symptoms feeling unreal purchase doxepin with mastercard, on the other anxiety symptoms 3-4 best buy doxepin, to detect and kill pathogenic organisms gaining entry through the gut. To complicate matters further, most of the gut is heavily colonized by approximately 1014 commensal microorganisms, which live in symbiosis with their host. They provide protection against pathogenic bacteria by occupying the ecological niches for bacteria in the gut. They also serve a nutritional role in their host by synthesizing vitamin K and some of the components of the vitamin B complex. However, in certain circumstances they can also cause disease, as we will see later. Mucosa-associated lymphoid tissue is located in anatomically defined microcompartments throughout the gut. They represent large aggregates of mucosal lymphoid tissue, which often become extremely enlarged in childhood because of recurrent infections, and which in the past were victims of a vogue for surgical removal. A reduced IgA response to oral polio vaccination has been seen in individuals who have had their tonsils and adenoids removed, which illustrates the importance of this subcompartment of the mucosal immune system. These have microfolds on their luminal surface, instead of the microvilli present on the absorptive epithelial cells of the intestine, and are known as microfold cells or M cells. Hence they are adapted to interact directly with molecules and particles within the lumen of the gut. M cells take up molecules and particles from the gut lumen by endocytosis or phagocytosis. This material is then transported through the interior of the cell in vesicles to the basal cell membrane, where it is released into the extracellular space. At their basal surface, the cell membrane of M cells is extensively folded around underlying lymphocytes and antigen-presenting cells, which take up the transported material released from the M cells and process it for antigen presentation. Although this tissue looks very different from other lymphoid organs, the basic divisions are maintained. Antigens are transported through M cells by the process of transcytosis and delivered directly to antigen-presenting cells and lymphocytes of the mucosal immune system. In addition to the organized lymphoid tissue in which induction of immune responses occurs within the mucosal immune system, small foci of lymphocytes and plasma cells are scattered widely throughout the lamina propria of the gut wall. As naive lymphocytes, they emerge from the primary lymphoid organs of bone marrow and thymus to enter the inductive lymphoid tissue of the mucosal immune system via the bloodstream. They may encounter foreign antigens presented within the organized lymphoid tissue of the mucosal immune system and become activated to effector status. From these sites, the activated lymphocytes traffic via the lymphatics draining the intestines, pass through mesenteric lymph nodes, and eventually wind up in the thoracic duct, from where they circulate in the blood throughout the entire body. This pathway of lymphocyte trafficking is distinct from and parallel to that of lymphocytes in the rest of the peripheral lymphoid system. Activated lymphocytes leave this tissue via draining lymph nodes and reenter the circulation through the thoracic duct. The right panel shows the efferent immune response in which primed lymphocytes reenter mucosal tissues throughout the body from the circulation, thereby disseminating a mucosal immune response. Naive lymphocytes recirculate constantly through peripheral lymphoid tissue, here illustrated as a lymph node behind the knee, a popliteal lymph node. Here, they may encounter their specific antigen, draining from an infected site in the foot. The distinctiveness of the mucosal immune system from the rest of the peripheral lymphoid system is further underlined by the different lymphocyte repertoires in the different compartments. These highly specialized T cells are abundant in the epithelium of the gut and have a restricted repertoire of T-cell receptor specificities. Unlike conventional T cells, many of these cells do not undergo positive and negative selection in the thymus (see Chapter 7), and express receptors with sequences that have undergone no or minimal divergence from their germline-encoded sequences. These cells may be classified in phylogenetic terms as being at the interface between innate and adaptive immunity.
Not all bacteria or bacterial infections cause disease; however anxietyzone symptoms purchase doxepin with visa, some always cause disease anxiety night sweats order doxepin with american express. The human body is colonized with numerous microbes (normal flora), many of which serve important functions for their hosts. The composition of the normal flora can be disrupted by antibiotic treatment, diet, stress, and changes in the host response to the flora. An altered normal flora can lead to inappropriate immune responses, causing inflammatory bowel diseases. Normal flora bacteria cause disease if they enter normally sterile sites of the body. Opportunistic bacteria take advantage of preexisting conditions, such as immunosuppression, to grow and cause serious disease. Disease results from the damage or loss of tissue or organ function due to the infection or the host inflammatory responses. The signs and symptoms of a disease are determined by the change to the affected tissue. Systemic responses are produced by toxins and the cytokines produced in response to the infection. The seriousness of the disease depends on the importance of the affected organ and the extent of the damage caused by the infection. The bacterial strain and inoculum size are also major factors in determining whether disease occurs; however, the threshold for disease production is different for different bacteria. For example, although a million or more Salmonella organisms are necessary for gastroenteritis to become established in a healthy person, only a few thousand organisms are necessary in a person whose gastric pH has been neutralized with antacids or other means. The longer a bacterium remains in the body, the greater its numbers, its ability to spread, and its potential to cause tissue damage and disease, and the larger the host response. Many of the virulence factors consist of complex structures or activities that are only expressed under special conditions (see Figure 13-6). The components for these structures are often encoded together in a pathogenicity island. Pathogenicity islands are large genetic regions in the chromosome or on plasmids that contain sets of genes encoding numerous virulence factors that may require coordinated expression. A pathogenicity island is usually within a transposon and can be transferred as a unit to different sites within a chromosome or to other bacteria. Disease is caused by damage produced by the bacteria plus the consequencesofinnateandimmuneresponsestotheinfection. Thelengthoftheincubationperiodisthetimerequiredforthebacteria and/or the host response to cause sufficient damage to initiate discomfortorinterferewithessentialfunctions. On invasion, the bacteria can travel in the bloodstream to other sites in the body. The skin has a thick, horny layer of dead cells that protects the body from infection. However, cuts in the skin, produced accidentally or surgically or kept open with catheters or other surgical appliances, provide a means for the bacteria to gain access to the susceptible tissue underneath. For example, Staphylococcus aureus and Staphylococcus epidermidis, which are a part of the normal flora on skin, can enter the body through breaks in the skin and pose a major problem for people with indwelling catheters and intravenous lines. The mouth, nose, respiratory tract, ears, eyes, urogenital tract, and anus are sites through which bacteria can enter the body. For example, the outer membrane of the gram-negative bacteria makes these bacteria more resistant to lysozyme, acid, and bile. A break in the normal barrier can allow entry of these endogenous bacteria to normally sterile sites of the body, such as the peritoneum and the bloodstream, to cause disease. This may be closest to the point of entry or due to the presence of optimal growth conditions at the site.
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The symptoms and course of the disease are presented in Figure 44-3 anxiety symptoms memory loss cheap doxepin 75mg online, and the characteristic rash is shown in Figure 44-4 anxiety from alcohol generic doxepin 75mg without a prescription. After a 5- to 17-day incubation period, the infected person experienced high fever, fatigue, severe headache, backache, and malaise, followed by the vesicular rash in the mouth and soon after on the body. The simultaneous outbreak of the vesicular rash distinguishes smallpox from the vesicles of varicella-zoster, which erupt in successive crops. Smallpox was the first disease to be controlled by immunization, and its eradication is one of the greatest triumphs of medical epidemiology. The last case of naturally acquired infection was reported in 1977, and eradication of the disease was acknowledged in 1980. Variolation, an early approach to immunization, involved inoculation of susceptible people with the virulent smallpox pus. Variolation was associated with a fatality rate of approximately 1%, a better risk than that associated with smallpox itself. In 1796, Jenner developed and then popularized a vaccine using the less virulent cowpox virus, which shares antigenic determinants with smallpox. Renewed interest is being paid to antiviral drugs that are effective against smallpox and other poxviruses. Newer, safer vaccines are being stockpiled in response to concerns regarding the use of smallpox in biowarfare. Vaccinia and Vaccine-Related Disease (Clinical Case 44-1) Vaccinia is the virus used for the smallpox vaccine. Smallpox was usually initiated by infection of the respiratory tract, with subsequent involvement of local lymph glands, which in turn led to viremia. Although the woman routinely insisted on using condoms during sex, a condom broke during vaginal intercourse with a new male sex partner. Military and had been vaccinated for smallpox 3 days before initiating his relationship with the woman. Military and other personnel are receiving vaccinia immunization for protection against weaponized smallpox. This increases the potential for unintentional transmission of the vaccinia vaccine virus. Other cases of vaccine-related vaccinia infection have included infants and individuals with atopic dermatitis, who had more severe consequences. Therefore, routine smallpox vaccination began to be discontinued in the 1970s and was totally discontinued after 1980, but it has been reintroduced for military personnel and first responders in case of biowarfare. Complications from vaccination included encephalitis and progressive infection (vaccinia necrosum), the latter occurring occasionally in immunocompromised patients who were inadvertently vaccinated. Recent cases of vaccinerelated disease have been noted in family members and contacts of immunized military personnel (see Clinical Case 44-1). Box 44-4 Clinical Summary Molluscum contagiosum: A 5-year-old girl has a group of wartlike growths on her arm that exude white material on squeezing. Orf, Cowpox, and Monkeypox Human infection with the orf (poxvirus of sheep and goat) or cowpox (vaccinia) virus is usually an occupational hazard resulting from direct contact with lesions on the animal. A single nodular lesion usually forms on the point of contact, such as the fingers, hand, or forearm, and is hemorrhagic (cowpox) or granulomatous (orf or pseudocowpox) (Figure 44-5). Vesicular lesions frequently develop and then regress in 25 to 35 days, generally without scar formation. The virus can be grown in culture or seen directly with electron microscopy but is usually diagnosed from the symptoms and patient history. The more than 100 cases of illnesses resembling smallpox have been attributed to the monkeypox virus. Except for the outbreak in Illinois, Indiana, and Wisconsin in 2003, they all have occurred in western and central Africa, especially Zaire. Monkeypox causes a milder version of smallpox disease, including the pocklike rash. They begin as papules and then become pearl-like umbilicated nodules that are 2 to 10 mm in diameter and have a central caseous plug that can be squeezed out. They are most common on the trunk, genitalia, and proximal extremities and usually occur in a cluster of 5 to 20 nodules. The disease is more common in children than adults, but its incidence is increasing in sexually active and immunocompromised individuals. The diagnosis of molluscum contagiosum is confirmed histologically by the finding of characteristic large, eosinophilic, cytoplasmic inclusions (molluscum bodies) in epithelial cells (see Figure 44-6B).
E1 Case Study and Questions An 18-year-old man fell on his knee while playing basketball anxiety 37 weeks order doxepin online. The knee was swollen and remained painful the next day anxiety symptoms crying purchase doxepin now, so he was taken to the local emergency department. Clear fluid was aspirated from the knee, and the physician prescribed symptomatic treatment. Two days later, the swelling returned, the pain increased, and erythema developed over the knee. Aspiration of the knee yielded cloudy fluid, and cultures of the fluid and blood were positive for Staphylococcus aureus. How do the clinical symptoms of these diseases differ from the infection in this patient Which structures in the staphylococcal cell and which toxins protect the bacterium from phagocytosis The organism could have been introduced into the joint either by direct extension from the skin surface, by hematogenous spread, or when the synovial fluid was originally aspirated. Even though the skin surface appeared to be unbroken, localized trauma of this nature can introduce organisms into the deeper skin tissues. Alternatively, bacteria on the skin surface could have been introduced into the joint when the accumulated fluid was originally aspirated. Staphylococcal diseases can be subdivided into two categories: localized pyogenic infections and disseminated toxin-mediated infections. Five groups of cytolytic toxins are responsible for the tissue destruction characteristic of pyogenic staphylococcal infections: alpha toxin, beta toxin (sphingomyelinase C), delta toxin, gamma toxins (5 different bicomponent toxins), and P-V leukocidin toxin. A variety of staphylococcal enzymes have also been implicated in disease, including coagulases (bound and free), catalase, hyaluronidase, fibrinolysin (staphylokinase), lipases, nuclease, and -lactamases. Staphylococci are protected from phagocytosis by their capsule; a loosely bound slime layer consisting of monosaccharides, proteins, and small peptides; and protein A. Effective treatment of staphylococcal infections requires drainage of purulent collections and effective antibiotics. Because resistance to antibiotics is common, antimicrobial susceptibility tests must be performed. If resistance is determined (commonplace in many hospitals), vancomycin should be used to treat serious staphylococcal infections. An exudate was present over the tonsillar area of the throat and covered his tongue. The clinical diagnosis of scarlet fever was confirmed by positive antigen test for group A Streptococcus from a throat specimen. The genera Streptococcus and Enterococcus include a large number of species capable of causing a wide spectrum of diseases. WhatsitesofthehumanbodyarenormallycolonizedwithStreptococcus pyogenes, Streptococcus agalactiae, and Streptococcus pneumoniae Anginosus group-abscess formation; mitis group- septicemia in neutropenic patients and endocarditis; salivarius group-endocarditis; mutans group-dental caries; bovis group-bacteremia associated with gastrointestinal cancer and meningitis. The bacteria are resistant to many commonly used antibiotics (oxacillin, cephalosporins, aminoglycosides, vancomycin), so infections are most commonly seen in patients hospitalized for prolonged periods and receiving broad-spectrum antibiotics. The microscopic morphology of enterococci (gram-positive cocci in pairs) is also a distinguishing feature (staphylococci are in clusters, and most streptococci are in long chains). Most species are facultative anaerobes, and some grow only in an atmosphere enhanced with carbon dioxide (capnophilic growth). Their nutritional requirements are complex, necessitating the use of blood- or serum-enriched media for isolation. Carbohydrates are fermented, resulting in the production of lactic acid, and unlike Staphylococcus species, streptococci and enterococci are catalase negative. The number of genera of catalase-negative, gram-positive cocci that are recognized as human pathogens continues to increase; however, Streptococcus and Enterococcus are the genera most frequently isolated and most commonly responsible for human disease. The other genera are relatively uncommon and are listed in Table 19-2 but are not discussed further. The classification of more than 100 species within the genus Streptococcus is complicated because three different overlapping schemes are used: (1) serologic properties: Lancefield groupings (originally A to W); (2) hemolytic patterns: complete (beta []) hemolysis, incomplete (alpha []) hemolysis, and no (gamma []) hemolysis; and (3) biochemical (physiologic) properties. Although this is an oversimplification, it is practical to think that the streptococci are divided into two groups: (1) the -hemolytic streptococci, which are classified by Lancefield grouping, and (2) the -hemolytic and -hemolytic streptococci, which are classified by biochemical testing.
