MMIC PBL2 - Blog 2

Fungal

Fungal Diseases	Treatment	Prevention
Tinea capitis(scalp ringworm)	-Oral antifungal medicines-Oral antifungal pills such as griseofulvin, terbinafine, itraconazole, fluconazole and ketoconazole	-Medicated shampoo maybe used to reduce the risk of spreading the scalp ringworm to someone else:such as selenium sulfide shampoo and ketoconazole shampoo -Keep skin dry and cool
Tinea cruris(jock itch)	-Antifungal creams or ills	-Keep skin dry and cool
Tinea pedis(athelete’s foot)	Antifungal ointment, lotion, powder or spray such as terbinafine (Lamisil AT), clotrimazole (Lotrimin AF) and miconazole (Micatin)- Oral medications such as itraconazole (Sporanox), fluconazole (Diflucan) and terbinafine (Lamisil)	-Keep skin dry and cool
Sporotrichosis	-Oral potassium iodide such as itraconazole (Sporanox)	nil
Histoplasmosis	-Antifungal medications such as amphotericin B (Fungizone IV) and itraconazole (Sporanox)	-No vaccine is available. -Itraconazole is used for chronic suppression,AIDS patients.
Disseminated candidiasis	- Antifungal medications such as Amphotericin B and Fluconazole.	-Predisposing factors shold be reduced or eliminated. -Oral thrush can be prevented by using Clotrimazole troches/nystatin "swish & swallow". -No vaccine is available..
Chronic mucocutaneous candidiasis	-Antifungal agents, immunologic therapies, and combination therapy -Such as ketoconazole	-Predisposing factors shold be reduced or eliminated. -Oral thrush can be prevented by using Clotrimazole troches/nystatin "swish & swallow". -No vaccine is available.
Cryptococcal meningitis	-Antifungal medications such as amphotericin B	-Fluconazole (Diflucan) is used to prevent the cryptococcal infection from coming back (maintenance treatment). -No vaccine is available.
Aspergillosis	-Oral corticosteroids-Antifungal medications such as amphotericin B and oriconazole	-No vaccine is available.

Virus

Dieases/virus	Treatment	Prevention
Hep A	There is no specific treatment for HAV and most people fight off the virus naturally, returning to full health within a couple of months. The doctor will advise avoiding alcohol and fatty foods as these can be hard for the liver to process and may exacerbate the inflammation.	Hepatitis A immunisation is given in a series of injections. The first single injection in the arm gives protection for a year. The second booster injection at 6 to 12 months extends protection for up to 10 years.
HEPATITIS B	In the majority of patients with active HBV, symptoms will not be severe and treatment will not be required Antiviral medication is given as treatment to those with chronic symptoms to help prevent further liver damage. These medications may be injected or given in pill form. Examples are Interferon Alpha, Lamivudine and Baraclude	Three immunisation injections are given over a period of 3-6 months. A blood test is taken once the course of injections is completed to check that they have worked. Immunity should last for at least 5 years.
NAIROVIRUS	The antiviral drug ribavirin has been used in treatment of established CCHF infection with apparent benefit. Both oral and intravenous formulations seem to be effective.	Avoidance of areas where tick vectors are abundant and when they are active (Spring to Fall); Regular examination of clothing and skin for ticks, and their removalUse of repellents.
WEST NILE FEVER	There is no specific treatment for West Nile virus infection. Intensive supportive therapy is directed toward the complications of brain infections. Anti-inflammatory medications, intravenous fluids, and intensive medical monitoring may be required in severe cases	When you are outdoors, use insect repellent containing an EPA-registered active ingredient.
RABIES	If rabies vaccine treatment is called for, it should be started as soon as possible after exposure. Counting the first day of vaccine treatment as day 0, injections are administered on days 0, 3, 7, 14, and 28.	The rabies vaccine is administered after exposure to the virus. No matter where the wound, authorities emphasize that the first and most valuable preventive measure is thorough cleaning of the site with soap and water, and immediate medical attention.
JAPANESE ENCEPHALITIS	nil	In general, vaccine should be offered to persons spending a month or longer in endemic areas during the trans-mission season, especially if travel will include rural areas. Use of insect repellants
YELLOW FEVER	Serious cases of yellow fever always need hospital treatment. As there are no products that combat the virus itself, the doctor can only treat the symptoms. If there is a lack of fluid in the body, leading to disturbances in the electrolyte balance, this can be remedied by administration of fluids by intravenous drip. In mild cases, the pain may be relieved with simple painkillers. High temperatures can be treated by cooling the patient and giving them appropriate medicines to lower the temperature, such as aspirin (eg Disprin) or ibuprofen (eg Nurofen).	Vaccination available: This vaccine contains a live, weakened form of the yellow fever virus. It provokes the body's immune response without causing the disease.
Leishmania virus	itraconazole/ Fluconazole/ Paromomycin/ miltefosine (impavido)	· Stay in well-screened or air-conditioned areas as much as possible. Avoid outdoor activities, especially from dusk to dawn, when sand flies are the most active.· When outside, wear long-sleeved shirts, long pants, and socks. Tuck your shirt into your pants. · Apply insect repellent on uncovered skin and under the ends of sleeves and pant legs. Follow the instructions on the label of the repellent. The most effective repellents are those that contain the chemical DEET (N,N-diethylmetatoluamide). The concentration of DEET varies among repellents. Repellents with DEET concentrations of 30%-35% are quite effective, and the effect should last about 4 hours. Lower concentrations should be used for children (no more than 10% DEET). Repellents with DEET should be used sparingly on children from 2 to 6 years old and not at all on children less than 2 years old.· Spray clothing with permethrin-containing insecticides. The insecticide should be reapplied after every five washings. · Spray living and sleeping areas with an insecticide to kill insects.· If you are not sleeping in an area that is well screened or air-conditioned, use a bed net and tuck it under your mattress. If possible, use a bed net that has been soaked in or sprayed with permethrin. The permethrin will be effective for several months if the bed net is not washed. Keep in mind that sand flies are much smaller than mosquitoes and therefore can get through smaller holes. Fine-mesh netting (at least 18 holes to the inch; some sources say even finer) is needed for an effective barrier against sand flies. This is particularly important if the bed net has not been treated with permethrin. However, it may be uncomfortable to sleep under such a closely woven bed net when it is hot.NOTE: Bed nets, repellents containing DEET, and permethrin should be purchased before traveling and can be found in hardware, camping, and military surplus stores
RIFT VALLEY FEVER	Ribavirin	. Hepatotoxic medication as well as aspirin and NSAIDs should be avoided during the acute disease. Contact with sick or dead animals must be avoided.Smithburn vaccine (single dose, life-long protection), or vaccination with the formol-inactivated vaccine (boosters needed). For personal protection covering clothing (long sleeves, long trousers), insect repellents (best with DEET) and impregnated mosquito nets are adequate in normal situations. Barrier-nursing is indicated in the care of patients. There is still no commercial vaccine available for humans. It is true that experimental cell-culture vaccines for medical use do exist, but they are not easy to obtain.

General precautions to be taken when at camp
Preferably apply insect repellent whenever the individual is in the jungle and also apply before sleeping. This is to lower the risk of getting beaten by insects (sandflies, mosquitoes, etc.). Before consuming food, ensure to wash hands with clean water or boiled river/ stream water to reduce chances of consuming vectors of viruses. Ensure consumption of fluids from clean bottled water or boiled water from water bodies. Observe good personal hygiene to reduce chances of being infected by viruses and to reduce chances of transmitting viruses to other platoon members. Quarantine sick individuals to reduce chances of spreading the viruses contracted. Clean wounds or cuts properly to reduce chances of infection.

Protozoa

Dieases	Treatment	Prevention
Schistosomiasis	Praziquantel/ Oxamniquine/ Mirazid	· Swimming in the ocean and in chlorinated swimming pools is generally thought to be safe · Drink safe water(don’t drink water coming directly from canals, lakes, rivers, streams or springs is safe, you should either boil water for 1 minute or filter water before drinking it. Boiling water for at least 1 minute will kill any harmful parasites, bacteria, or viruses present. Iodine treatment alone WILL NOT GUARANTEE that water is safe and free of all parasites. · Bath water should be heated for 5 minutes at 150o F. Water held in a storage tank for at least 48 hours should be safe for showering · Vigorous towel drying after an accidental, very brief water exposure may help to prevent the Schistosoma parasite from penetrating the skin. You should NOT rely on vigorous towel drying to prevent schistosomiasis Castor oil as an oral- penetration
Balantidiasis	Tetracycline/ metronidazoleiodoquinol / paromomycin.	· Purification of drinking water. Water can be purified by filtering, boiling, or treatment with iodine. · Proper food handling. Measures include protecting food from contamination by flies, cooking food properly, washing one's hands after using the bathroom and before cooking or eating, and avoiding foods that cannot be cooked or peeled when traveling in countries with high rates of balantidiasis. · Careful disposal of human feces. Monitoring the contacts of balantidiasis patients. The stools of family members and sexual partners of infected persons should be tested for the presence of cysts or trophozoites.
Cholera	Tetracycline/ azithromycin/ oral rehydration solution/ mixture or salts, sugar and water drunk in large amount	· Wash your hands. Frequent hand washing is the best way to control cholera infection. Wash your hands thoroughly with hot, soapy water, especially before eating or preparing food, after using the toilet, and when you return from public places. Carry an alcohol-based hand sanitizer for times when water isn't available. · Avoid untreated water. Contaminated drinking water is the most common source of cholera infection. For that reason, drink only bottled water or water you've boiled or disinfected yourself. Hot beverages such as coffee and tea as well as bottled or canned soft drinks, and wine and beer are generally safe. Carefully wipe the outside of all bottles and cans before you open them and ask for drinks without ice. Use bottled water to brush your teeth. · Eat food that's completely cooked and hot. Choose food that's been thoroughly cooked and is served hot. Cholera bacteria can survive on room temperature food for up to five days and aren't destroyed by freezing. It's best to avoid street vendor food, but if you do buy it, make sure your meal is cooked in your presence and served hot. · Avoid sushi. Don't eat raw or improperly cooked fish and seafood of any kind. · Be careful with fruits and vegetables. When you're traveling, make sure that all fruits and vegetables that you eat are cooked or have thick skins that you peel yourself. Avoid lettuce in particular because it may have been rinsed in contaminated water. · Be wary of dairy foods. Avoid ice cream, which is often contaminated, and unpasteurized milk. Cholera vaccine. Because travelers have a low risk of contracting cholera and because the traditional injected vaccine offers minimal protection, no cholera vaccine is currently available in the United States. A few countries offer two oral vaccines that may provide longer and better immunity than the older versions did. If you'd like more information about these vaccines, contact your doctor or local office of public health. Keep in mind that no country requires immunization against cholera as a condition for entry.
Amebiasis	metronidazole, paromomycin, iodoquinol, or diloxanide furoate	· Drinking only water that has been bottled in sanitary conditions or boiled (water-purifying tablets are ineffective against amebic cysts) · Eating only cooked or peeled vegetables or fruits · Protecting food from fly contamination Washing hands after defecation and before preparing or eating food
Cryptosporidiosis	Nitazoxanide	Stools of patients with cryptosporidiosis are highly infectious · Frequent washing of the hands, including under the fingernails · Not eating unwashed fruits unless peeled · Boiling water if there is any doubt about its source · Boiling stream or river water for three minutes · Using filter paper with pore size of 1 micro<>
Cyclosporiasis	trimethoprium- sulfamethoxazole/ bactrim / septra/ cotrim	· Drinking only water that has been bottled in sanitary conditions or boiled (water-purifying tablets are ineffective against amebic cysts) · Eating only cooked or peeled vegetables or fruits · Protecting food from cyclosporasis contamination Washing hands after defecation and before preparing or eating food
Toxoplasmosis	pyrimethamine / trisulfapyrimidines / sulfadiazine./ folinic acid/ spiramycin	· Make sure your physician checks your blood for toxoplasma antibodies . Use work gloves and wash your hands afterwards. · Control flies and cockroaches as much as possible. They can spread contaminated soil or cat feces onto food. · Avoid eating raw or undercooked meat (or poultry) and unwashed fruits and vegetables. · Wash your hands thoroughly before you eat and after handling raw meat, soil, sand or cats. · Avoid rubbing your eyes or face when preparing food, and wipe the counter clean afterwards. Avoid eating raw eggs and drinking unpasteurized milk.
Giardiasis	metronidazole (Flagyl)/ furazolidone (Furoxone)/ paromycin (Humatim), / quinacrine (Atrabine)	· Frequent washing of the hands, including under the fingernails · Not eating unwashed fruits unless peeled · Boiling water if there is any doubt about its source · Boiling stream or river water for three minutes · Using filter paper with pore size of 1 micro <>
Malaria	Metronidazole/ Nitazoxanide/ Furazolidone/ Tinidazole/ aminoglycoside paromomycin/ chloroquine/ mefloquine(lariam)/ primaquine, quinine/ pyrimethamine-sulfadoxine (Fansidar)/ doxycycline/ artemisin- derivatives/ atovaquone-proguanil (malarone)	· evaluating the risk of exposure to infection · preventing mosquito bites by using DEET mosquito repellant, bed nets, and clothing that covers most of the body chemoprophylaxis (preventive medications)
Leishmaniasis	Na stibogluconate (Na antimony gluconate) / meglumine antimonite/ liposomal amphotericin/ pentamidine/ itraconazole/ Fluconazole/ Paromomycin/ miltefosine (impavido)	insect repellents containing DEET provide protection. Insect screens, bed nets,and clothing are more effective if treated with permethrin or pyrethrum, because the tiny flies can penetrate mechanical barriers. Vaccines are not currently available. Wear long selves shirt and long pants and sock.(tuck in shirt into the pants)

References

http://www.itg.be/itg/DistanceLearning/LectureNotesVandenEndenE/13_Arbovirusesp5.htm#T10
http://www.medicinenet.com/leishmaniasis/page4.htm

MMIC PBL 2

Virus

Microbe	Transmission	Signs and symptoms	Disease	Geographical distribution
Hepatitis A virus	Fecal-oral route	Diarrhea and nausea with possible acute infection	Hepatitis A	Worldwide, but most common where sanitary conditions are poor and the safety of drinking water is not well controlled
Hepatitis B virus	Parenteral route	Similar to HAV with higher possibilities of leading to chronic infections and liver cancer	Hepatitis B	Worldwide, but with differing levels of endemicity. In north America, Australia ,northern and western Europe and New Zealand, prevalence of chronic HBV infection is relatively low (less than 2% of the general population)
Nairovirus	Bite from Hyalomma tick, animal reservoirs	Fever, shaking chills, severe headache, rash and possible hepatomegaly	Crimean- Congo Hemorrhagic Fever	Nil
Viruses belonging to the Flaviviridae family	Bite from Mosquitoes ( eg. Culex tritaeniorhynchus) or Ticks, Birds serve as the reservoir	Fever, drowsiness, facial flushing, lymph node Largement, conjunctival infection	West Nile Fever	Nil
Flavi- viruses	Bites from mosquitoes, most commonly Aedes aegypti, a day biting mosquito	Dengue hemorrhagic fever, rash, headache, respiratory manifestations that mimic a cold	Dengue	Dengue fever is widespread in tropical and subtropical regions of central and south America and south and south-east Asia and also occurs in Africa; in these regions , dengue is limited to altitudes below 600 metres (2,000 feet)
Alphavirus	Bite from Culex mosquito , Birds serve as the reservoir	Fever, rash and polyarthritis	Sindbis	Nil
Phlebovirus	Bite from mosquitoes, exposure to infected animals and possible aerosol	Nonspecific febrile reaction with fever, nausea and possible visual loss	Rift Valley Fever	Nil
Viruses from Rhabdoviridae family	Open cuts or wound in skin or mucous membranes via bites or infected animal saliva	Fever, severe headache, malaise ,possible neurologic Manifestations	Rabies	Rabies is present in animals in many countries worldwide. Most cases of human infection occur in developing countries
Phlebo- viruses	Bites from sandfly (Phleobotomus papatasi)	Fever, severe frontal headache, nausea, vomiting, possible aseptic Meningitis	Sandfly fever	Nil
Leishmania- viruses	Leishmania species	Infection with Leishmania	Leishmania- virus	Nil
Japanese encephalitis (JE)virus, which is a flavivirus	The Japanese encephalitis virus is transmitted by various mosquitoes of the genus Culex	asymptomatic (e.g. cause no symptoms). In symptomatic cases, severity varies ;mild infections are characterized by febrile headache or aseptic meningitis	Japanese encephalitis	Nil
an arbovirus of the Flavivirus genus	Bites from mosquitoes (Aedes aegypti)	asymptomatic, most lead to an acute illness characterized by two phases. Initially, there is fever, muscular pain, headache, chills, anorexia, nausea and/ or vomiting, often with bradycardia	yellow fever	The yellow fever virus is endemic in some tropical areas of Africa and central and south America. The number of epidemics has increased since the early 1980s. Other countries are considered to be at risk of introduction of yellow fever due to the presence of t he vector and suitable primate hosts (including Asia, where yellow fever has never been reported)

Fungal

Causes of FUNGUS DISEASES
Fungal infection outbreak could happen in a clinical setting where climate are often hot and high humidity such as tropical areas like Indonesia. These diseases are caused by poor personal health practices (harsh living conditions of NS soldier). The jungle environment promotes fungus and bacterial diseases of the skin and warm water immersion skin diseases. Bacteria and fungi are tiny plants which multiply fast under the hot, moist conditions of the jungle. Sweat-soaked skin invites fungus attack. The following are common skin diseases that are caused by long periods of wetness of the skin:

Warm Water Immersion Foot. This disease occurs usually where there are many creeks, streams, and canals to cross, with dry ground in between. The bottoms of the feet become white, wrinkled, and tender. Walking becomes painful.
Chafing. This disease occurs when soldiers must often wade through water up to their waists, and the trousers stay wet for hours. The crotch area becomes red and painful to even the lightest touch.
Most skin diseases are treated by letting the skin dry.

Microbe	Transmission	Signs and symptoms	Disease	Geographical distribution
Dermatophytes, e.g: Microsporum, Trichophyton, epidermophyton sp	Direct contact with skin, usually on warm, sweaty and humid part of the body, hair and nails,feet.	typical ringworm lesion, itching, scaling, inflammation, and blisters	tinea capitis(scalp ringworm), tinea cruris(jock itch) and tinea pedis(athelete’s foot)	contact with infected lesions, soiled or contaminated articles such as shoes and towels, almost anywhere in the world
Sporothrix schenckii	mold spores enter skin in puncture wounds by thorns in jungle	small bumps on skin but painless, local abscess and ulcerative nodules	sporotrichosis	soil, wood, sphagnum moss, and decaying vegetation throughout the world
Histoplasma Capsulatom	Inhalation of airborne asexual pores causing acute respiratory diseases	Often no symptoms but fever, cough, malaise, respiratory symptoms can occur.	Histoplasmosis	grows preferentially in soil enriched with bird droppings
Candida Albicans	Part of the normal flora of skin, mucous membrane and GI tract, can invade tissue if the infected person is injured or wounded	: itchy skin rash, skin inflammation, skin lesions on moisture-damaged skins, rash in e penis area	disseminated candidiasis and chronic mucocutaneous candidiasis	Human body
Aspergillus fumigatos	Inhalation of airborne spores and their invasion through a wound or other tissue injury	Fever, cough, pneumonia, endocarditis, eosinophilia	Aspergillosis	live in soil, commonly in decaying vegetation, such as fermenting compost piles and damp hay.
Cryptococcus neoformans	Inhalation of airborne yeast cells, affects the central nervous system and the lungs in people with weakened immune systems.	early lung infection often has no symptoms, meningitis, encephalitis and headache.	Cryptococcosis, especially Cryptococcal meningitis	live in soil, especially when enriched with pigeon droppings

Prevention of FUNGUS DISEASES in soldiers
To prevent these diseases, soldiers should:

• Bathe often, and air- or sun-dry the body as often as possible.
• Wear clean, dry, loose-fitting clothing whenever possible.
• Not sleep in wet, dirty clothing. Soldiers should carry one dry set of clothes
• just for sleeping. Dirty clothing, even if wet, is put on again in the morning.
• This practice not only fights fungus, bacterial, and warm water immersion
• diseases but also prevents chills and allows soldiers to rest better.
• Not wear underwear during wet weather. Underwear dries slower than jungle fatigues, and causes severe chafing
• Take off boots and message feet as often as possible.
• Dust feet, socks, and boots with foot powder at every chance.
• Always carry several pairs of socks and change them frequently.
• Keep hair cut short.

Protozoa

Microbe	Transmission	Signs and symptoms	Disease	Geographical distribution
Leishmaniasis species	sand fly	fever, damage to the spleen and liver, and anaemia, Visceral/ Cutaneous/ Diffuse cutaneous /Mucocutaneous leishmaniasis	Leishmaniasis	Jungle setting: large number of mosquitoes and sand fly
Plasmodium falciparum and malariae	bites from Female anopheline mosquito	Moderate to severe shaking chills High fever, Profuse sweating as body temperature falls, General feeling of unease and discomfort, (malaise), Headache ,Nausea, Vomiting, Diarrhea	Malaria	Occur in many tropical and sub-tropical countries- P. falciparum and P. malariae is most common in Asia
Giardia	Contaminated food and water Raw food like fruits and vegetables	Abdominal pain, Watery diarrhea Foul smelling gas and burping, Mild fever, sometimes with chills, Malabsorption, where nutrients are not absorbed, frequently with weight loss	Giardiasis	Found in surface waters all over the Earth and spread in the feces of both humans and animals
Toxoplasma gondii	Contaminated food and water Raw food like fruits and vegetables	headache, chronic malanise, fever lymphadenopathy	Toxoplasmosis	almost everywhere from surface of water to contaminated veggies and fruits to soil and infects warm blooded vertebrates
Cryptosporidium	Contaminated food and water Raw food like fruits and vegetables /faecal-oral route or swimming	Dehydration, Malnutrition, Weight loss, Stomach cramps or pain, Fever, Nausea , Malaise , Vomiting	Cryptospori- diosis	Found in surface waters all over the Earth and spread in the feces of both humans and animals
Cyclospora cayetanensis	Contaminated food and water Raw food like fruits and vegetables	Headache, Nausea, Vomiting, sever Diarrhea, bloating, muscle aching, fatigue and asymptomatic	Cyclosporiasis	mainly in America and Canada
Entamoeba histolytica	Contaminated food and water Raw food like fruits and vegetables	sever diarrhea, abscesses in the intestine, liver, and other organs	Amebiasis	Entamoeba histolytica is endemic in tropical countries ,usually found in water, decaying organic matter, soil, and sewage, is of particular interest to contact lens wearers
Naegleria fowleri	nasal passage via swimming and diving	disease primary amebic meningoen- cephalitis (PAM), a brain inflammation	Naegleria infection	found in environment water and soil worldwide, commonly in Warm bodies of freshwater, such as lakes, rivers, Geothermal water such as hot springs, Warm water discharge from industrial plants, Poorly maintained and minimally chlorinated swimming pools
Balantidium coli	Contact with pig feces or soil contaminated with pig feces	severe diarrhea and intestinal abscesses	Balantidiasis	common in tropical regions and many developing countries in the tropical region lack proper water structures for much of the poor, rural population such as Bolivia, the Philippines, and Papua New Guinea
Vibrio cholerae	Faceal-oral route or contaminated food and drink sand more prevalent in warmer cilmate	sever diarrhoea, dehydration, shock , muscle cramps , nausea and vomitting	Cholera	Cholera is most common in Africa, southern and Southeast Asia, and the Middle East, although outbreaks have occurred in Japan , Australia, and Europe
S.japonicum, S.mekongi, S.mansoni, S.intercalatum and S.haematobium	faecal oral route	Katayama fever, abdominal pain, hematuria, weakness, headaches , joint and muscle pain, diarrhea, nausea, producing seizures or transverse myelitis as a result of mass lesions of the brain or spinal cord and cough	Schistoso- miasis	This infection occurs widely throughout the tropics and subtropics

References

http://www.microbiologybytes.com/iandi/6b.html

http://www.mayaparadise.com/diseasee.htm

http://www.nuim.ie/staff/dpringle/courses/mg/chapter02.pdf

http://human-infections.suite101.com/article.cfm/protozoan_parasites_in_dirt\

http://www.who.int/water_sanitation_health/dwq/admicrob5.pdf

Medical Microbiology- PBL 1 ( second blog)

Case study 1
List of microbes: Staphylococcus aureus, Staphylococcus saprophyticus, Enterococcus faecalis. Escherichia coli, Enterobacter, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Chlamydia trachomatis.

A gram stain will be done first for the suspected bacteria that can cause UTI, before proceeding to any laboratory investigation.

Gram positive bacteria: Staphylococcus aureus, Staphylococcus saprophyticus, Enterococcus faecalis.Gram negative bacteria: Escherichia coli, Enterobacter, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Chlamydia trachomatis.

Biochemical and Culture Testing

Possible Organisms	Staphylococcus aureus	Staphylococcus saprophyticus	Enterococcus faecalis
Gram Stain :positive	cocci(clusters)	cocci(clusters)	cocci(chains)
Culture on Sheep blood agar	haemolytic, yellow colonies	non-haemolytic white colonies	gamma non-haemolytic white colonies( but can show weak alpha haemolysis)
Catalase test	positive	positive	negative
Coagulase test	positive	negative	nil

Possible Organisms	Escherichia coli	Enterobacter sp	Pseudomonas aeruginosa	Klebsiella pneumoniae	Proteus mirabilis
Gram Stain: negative	bacilli	bacilli	bacilli	bacilli	bacilli
Culture on Mac Conkey	pink lactose fermenting colonies	very weak lactose fermenters	non-lactose fermenting colonies producing blue-green pigments	pink lactose fermenting colonies	non-lactose fermenting colonies
Culture on eosin methylene blue (EMB)	metallic green sheen with dark colonies	brown-centered with pale blue colonies	colorless colonies indicating no lactose fermentation and acid production	brown dark-centered colonies indicating lactose fermentation and acid production	colorless colonies indicating no lactose fermentation and acid production
oxidase	negative	negative	positive	negative	negative
*Triple sugar iron (TSI)	acidic slant/acidic deep	alkaline slant/acidic deep	No change	alkaline slant/acidic deep	alkaline slant with black precipitate

acidic slant/acidic deep: ferment lactose and glucose
alkaline slant/acidic deep : ferment glucose only
No change: no carbohydrate fermentation
Black precipitate: H2S production

If oxidase test is negative, proceed to IMViC biochemical test

IMViC	Escherichia coli	Enterobacter sp	Klebsiella pneumoniae	Proteus mirabilis
Indole	+	-	-	-
Methyl red	+	-	-	+
Voges proskauer	-	+	+	-
Citrate test	-	+	+	+
Urease	-	-	-	+

Antibiotic Susceptibility test
5 antibiotics: Gentamycin, Ceftadizime,Cefuroxime, Ampicillin and Ciprofloxacin. Varying zone diameter size can be observed for both the gram positive and negative bacteria.

If Chlamydia trachomatis is highly suspected, as it is a common STD that can cause UTI, some portion of the urine sample can be send for DNA based analysis method such as polymerase chain reaction(PCR).

Case study 2 Besides Salmonella, there are also several other possible microorganisms that could lead to enterocolitis or cause the diarrhea in the patient. Here are the other possibilities:
1. Enterotoxigenic Escherichia coli
2. Campylobacter jejuni
3. Clostridium difficileShigella: S. dysenteriae, S. flexneri, S. boydii, and S. sonnei

Type of microbe	Microscopy test	Biochemical Test	Serology test	Culture
Salmonella	Gram Stain: Gram negative bacilli	TSI: alkaline slant/acid butt with H2S production Indole: Negative Methyl-red: Positive Voges-Proskauer: Negative Citrate: Positive	Slide agglutination test: serotyping using O, H and Vi antigens Tube agglutination test: detect agglutinating Ab to O & H Ag in patient’s serum	MacConkey agar: Observe plate for non-lactose fermenting (clear) colonies Hektoen agar: Observe plate for clear or green colonies and colonies with black centers (H2S production) Salmonella-Shigella agar: Observe plate for clear colonies and colonies with black centers (H2S production) XLD Agar: Observe plate for red colonies and colonies with black centers (H2S production)
Shigella	Gram Stain: Gram negative bacilli	TSI: Alkaline slant/acid butt but no H2S production Indole: Negative Methyl-red: Positive Voges-Proskauer: Negative Citrate: Negative	Slide agglutination test	MacConkey agar: Observe plate for non-lactose fermenting (clear) colonies Salmonella-Shigella agar: Observe plate for clear colonies and colonies WITHOUT black centers (no H2S production) Hektoen agar: Observe plate for clear or green colonies and colonies WITHOUT black centers (no H2S production)
Enterotoxigenic E.Coli	Gram Stain: Gram negative bacilli	TSI: Alkaline slant/acid butt with gas but not H2S production Indole: Positive Methyl-red: Positive Voges-Proskauer: Negative Citrate: Negative	Serotyping using O & H Ag	MacConkey agar: Observe plate for red/pink colonies (lactose-fermenting colonies) EMB agar: Observe plate for greenish metallic sheen
Campylobacter jejuni	Gram Stain: Gram negative bacilli that appear either comma or S- shaped	TSI: Alkaline slant/deep Oxidase: Positive	nil	Selective “CAMP” agar at 42ºC in microaerophilic environment (grow at 5% oxygen + 10% carbon dioxide)
Clostridium difficile	Gram Stain: Gram positive bacilli	nil	nil	Blood agar at human body temperatures

Antibiotic susceptibility testing:
1. Enterotoxigenic Escherichia coli:
• Ampicillin
2. Campylobacter jejuni
• Erythromycin
3. Shigella:
• Ampicillin
4. SalmonellaAmpicillin


Case study 3

Laboratory investigations:
Urine culture is to test to identify the exact type of bacteria causing infection.
Culture on:
1.Blood Agar Plate (BAP)
2.Eosin Methylene Blue (EMB) agar
3.MacConkey Agar (MAC)
4.Ordinary nutrient agar
5.Triple Sugar Iron (TSI) agar
All are grown under anaerobic conditions except for Pseudomonas spp. such as P. aeruginosa as it is a strict aerobe.

Microscopy
1.Gram stain
2.Fungal stain
Morphology are studied in terms of the microorganisms’ shape, arrangement, response to strain and specific structures.
Biochemical tests are done to indicate the presence or absence of enzyme(s), a group of enzymes or a whole metabolic pathway. This helps to identify microorganisms.

	Gram staining	Cultures (Under anaerobic conditions)	Biochemical tests	Antibiotic Susceptibility test
Escherichia coli	Gram-negative (pink) bacillus	1. Blood agar: Gamma hemolysis 2. Eosin Methylene Blue agar: Colonies with metallic green sheen 3. MacConkey agar: Pink colonies	1. Indole test: Positive 2. Methyl Red (MR) test: Positive 3. Voges-Proskauer (VP) test: Negative 4. Simmon’s citrate test: Negative 5. Oxidase test: Negative 6. Urease: Negative 7. TSI acid slant/acid butt with gas, no H2S	-Susceptibility depends on the type of strains - Beta-lactamase resistant strains are not sensitive to penicillin and cephalosporin - Non-resistant strains are sensitive to ampicillin and trimethoprim-sulfamethoxazole
Enterococcus faecalis	Gram-positive (purple) cocci	1. Blood agar: Non hemolytic 2. MacConkey agar: Pink colonies with mucoid appearance 3. Bile Esculin Agar: Ferric citrate indicator will turn black	1.Indole test: Negative 2. Voges-Prokauer test: Positive	-Resistant to aminoglycoside, penicillin and vancomycin when given individually -A synergistic combination of aminoglycoside and cell wall-active antibiotics such as ampicillin and vancomycin
Klebsiella pneumoniae	Gram negative (pink) bacillus, a large capsule can be observed	1. MacConkey agar: Pink colonies with mucoid appearance	1. Indole test: Negative 2. Methyl Red test: Negative 3. Voges-Prokauer test: Positive 4. Urease test: Positive	- Isolates from nosocomial infections are frequently resistant to multiple antibiotics - Susceptible to aminoglycoside (eg. gentamicin) and cephalosporin (eg. cefotaxime)
Pseudomonas aeruginosa	Gram-negative (pink) bacillus	1. Blood agar: Beta-hemolysis 2. MacConkey agar: Colourless colonies 3. Ordinary nutrient agar: Blue-green colonies	1. Indole test: Negative 2. Methyl Red test: Negative 3.Voges -Prokauer test: Negative 4. Catalase test: Positive 5. Oxidase test: Positive 6. TSI agar: Negative (Growth with typical metallic sheen) 7. Pyocyanin test: Positive 8. Urease test: Positive/Negative 9. Fluprescein test: Positive	- Highly multidrug resistant - Combination therapy: Penicillin derivatives, Ceftazidime, Ciprofloxacin, Aztreonam, Imipenam
Serratia marcescens	Gram-negative (pink) bacillus	1. MacConkey agar: Pink colonies 2. Ordinary nutrient agar: Red colonies	1. Indole test: Negative 2. Methyl Red test: Negative 3. Voges-Prokauer test: Positive 4. Urease test: Negative	- Antibiotic resistance vary greatly - Isolates from nosocomial infections are frequently resistant to multiple antibiotics - Susceptible to aminoglycoside (eg. gentamicin) and cephalosporin (eg. cefotaxime)
Proteus mirabilis	Gram-negative (pink) bacillus	1. Blood agar with phenylethyl alcohol: Colonies do not have swarming effect 2. MacConkey agar: Colourless colonies	1. Indole test: Negative 2. Methyl Red test: Positive 3.Voges-Prokauer test: Negative 4. Catalase test: Positive 5. Urease test: Positive 6. TSI agar: Black butt	- Sensitive to ampicillin, aminoglycosides and trimethoprim sulfamethoxazole

Case Study 4
1.Chlamydia pneumoniae
• Obligate intracellular bacterium
• Does not gram stain
• Affects adults and children

2. Haemophilus influenza
• Pleomorphic gram-negative bacillus
• Affects children and adults (especially with COPD-Chronic Obstructive Pulmonary Diseases)

3. Moraxella catarrhalis
• Oxidase positive
• Gram-negative diplococcus
• Affects children and adults with COPD

4. Pseudomonas aeruginosa
• Glucose-nonfermenting
• Gram-negative bacillus
• Affects adults and children, diabetic adults, nosocomial, CF (Cystic Fibrosis) patients

5. Streptococcus pneumoniae
• Gram-positive lancet-shaped cocci
• Appear in pairs or short chains
• Affects adults (mainly elderly)

6. Mycoplasma pneumoniae
• Smallest free-living organism
• Lacks a bacterial cell wall
• Does not gram stain

7. Staphylococcus aureus
• Gram-positive cocci in clusters
• Coagulase-positive
• Catalase-positive
• Produces Beta-lactamase

8. Paragonimus westermani
• Fluke (Trematode)
• Affects children and adults in endemic areas

9. Adenovirus
• Enveloped dsDNA (double-stranded DNA)
• Affects children and adults

10. Parainfluenza virus Type I, II, III
• Enveloped ssRNA (single-stranded RNA)
• Affects infants and young children

11. Bordetella pertussis
• Coccobacillary, encapsulated gram-negative rod
• Negative blood culture

Lab investigations

Wet mounts
• Observe for microbe structure – bacillus, cocci, lancet-shaped, size, etc.

Gram stain
• Positive gram stain – microbe will stain purple/ blue
• Negative gram stain – microbe will stain red/ pink

Acid-fast bacterium stain
• Stains mycobacterium that do not gram-stain due to their high lipid content

Direct fluorescent-antibody stain
• Histologic stain to detect spirochetes

Peripheral blood films
• Observe microbial activity in blood
• Most respiratory tract infections would have negative blood smears

Enzyme immunoassay
• Identifies organisms with known antiserum
• Specific antibody linked to its homologous antigen

Latex agglutination assay
• Latex beads coated with specific antibody
• Agglutination will occur in the presence of the homologous bacteria

Blood cultures
• Positive blood culture – microbial growth (gold, yellow colonies, etc.)
• Negative blood culture – no microbial growth

Bacteriologic sputum cultured on enriched agar
• Bordet-Gengou agar

Antibiotic susceptibility tests

Penicillin – a general antibiotic for penicillin sensitive isolates
Ceftriazone
Erythromycin
Tetracycline – eg. Doxycycline
Praziquantel

Case study 5
Possible microorganisms

Microorganism	Test	Result
Staphylococcus aureus	● Gram-staining ● Culturing on mannitol salt/blood agar ● Coagulase test ● Catalase test ● TSI	● Gram-positive, cluster-forming cocci ● Yellow or gold colonies, drop in pH (yellow area) / ß-hemolytic ● Positive ● Positive ● Acid slant/acid butt
Enterococci	● Gram-staining ● Catalase test	● Gram-positive cocci, occuring singly, in pairs, or in short chains ● Negatives
Coagulase-negative staphylococci	● Gram-staining ● Culturing on blood agar ● Coagulase test ● Catalase test	● Gram-positive, cluster-forming coccus ● Yellow or gold colonies ● Negative ● Positive
Escherichia coli	● Gram-staining ● Culture on EMB/ MacConkey's agar ● TSI agar ● Urease test ● Indole test ● Citrate test	● Gram-negative rod ● EMB:Lactose-fermenting, blue-black colonies with metallic green sheen ● MacConKey:Lactose-fermenting, red colonies ● Acid slant/acid butt with gas but no H2S ● Negative● Positive ● Negative
Pseudomonas aeruginosa	● Gram-staining● Culture on EMB/ MacConkey's agar ● TSI● Oxidase test ● Indole test ● Citrate	● Gram-negative rod ● EMB/MacConkey:Non-lactose fermenting colonies ● Alkaline slant/alkaline butt ● Positive ● Negative ● Positive
Enterobacter species	● Gram-staining ● Culture on EMB/ MacConkey's agar ● Urease test ● Vogues-Proskauer test ● Citrate test	● Gram-negative rod ● EMB: Lactose-fermenting, brown dark -centered, mucoid colonies ● MacConkey:Lactose-fermenting, pink mucoid colonies ● Negative ● Positive ● Positive
Proteus mirabilis	● Gram-staining ● Culture on EMB/ MacConkey's agar ● TSI ● IMVIC ● Urease test	● Gram-negative cocci ● EMB/MacConkey:Non-lactose fermenting colonies ● Alkaline slant/acid butt with H2S ● Indole: Negative ● Methyl-red: Positive ● Vogues-Proskauer: Negative ● Catalase: Positive ● Positive
Klebsiella pneumoniae	● Gram-staining ● Culture on EMB/ MacConkey's agar ● TSI ● Indole test ● Urease test ● Citrate test	● Gram-negative rod ● EMB: Lactose-fermenting, brown dark -centered, mucoid colonies ● MacConkey:Lactose-fermenting, pink mucoid colonies ● Acid slant/acid butt with some gas production, no H2S ● Negative ● Positive ● Positive

Antibiotic:
Methicillin
Vancomycin
Penicillin
Oxacillin


Case study 6
Antibiotic Susceptibility test 5 antibiotics: vancomycin, ciprofloxacin , Erythromycin, bactrim and cefamandole

Gram-negative	Test	Result
Gardnerella vaginalis	● Morphology ● Oxidase ● TSI ● IMViC ● Laboratory diagnosis /culture	●Bacilli ● negative ● Acidic slant/acidic deep ● Catalase (-) ● Chocolate agar and HBT agar: Small, circular, convex, gray colonies ●Colistin-oxolinic acid blood agar: Beta-hemolysis
Escherichia coli	● Morphology ● Oxidase ● TSI ● IMViC ● Laboratory diagnosis /culture	●Bacilli ● negative ● Acidic slant/acidic deep ● I(+),M(+), Vi(-),C(-), U(-) ● EMB: green sheen,fermenting colonies ●MacConkey agar: fermenting colonies
Neisseria gonorrhoeae	● Morphology ● Oxidase ● TSI ● Laboratory diagnosis /culture	●Bacilli ● positive ● Acidic slant/acidic deep ●Giemsa-stained ●PCR and ELISA ●Immunofluorescence
Chlamydia trachomatis	● Morphology ● Oxidase ● Laboratory diagnosis /culture	●cocci ● positive ●Giemsa-stained ●PCR and ELISA ●Immunofluorescence
Pseudomonas aeruginosa	● Morphology ● Oxidase ● TSI ● IMViC ● Laboratory diagnosis /culture	●Bacilli ● positive ● Alkaline slant/ alkaline butt ●Catalase (+) ●EMB and MacConkey agar: non-fermenting colonies

Gram - positive	Enterococcus faecalis	Staphylococcus saprophyticus
Morphology	Cocci( in pairs)	Bacilli
Catalase test	-	+
coagulase	Nil	-
Laboratory diagnosis /culture	Blood agar: non-hemolysis	Mac Conkey’s agar: Spherical, irregular grape-like cluster in culture

Other microbes	Trichomonas vaginalis	Candida albicans	Mycoplasma hominis
Morphology	acridine orange : pear-shaped, motile, flagellated protozoan	single-celled, diploid fungus	round, pear shaped and even filamentous
Laboratory diagnosis /culture	Trichomonas Direct Enzyme Immunoassay and Fluorescent Direct Immunoassaysaline wet preparation : motile trichomonads and increased PMNs (ratio of PMNs to vaginal epithelial cells)	Blood agar plates: large, round, white or cream colonies	Mycoplasma GU Culture System: ‘fried egg’ and granular appearance colonies

Medical Microbiology- PBL 1

Learning issues:
1. Define the possible diagnosis
2. List down the possible causative agent

Case Study 1
Patient: Female/27 years old
Signs and symptoms: Fever, chills and dysuria
Suspected Diagnosis: Urinary tract infection
Specimen collected: Urine

The female patient in case 1 was diagnosed with urinary tract infection. UTI occurs due to the infection of microorganisms in the bladder,urethra and kidneys. It can be further classified as cystitis( bladder infection) or pyelonephritis( kidney infection). The patient showed common UTI symptoms seen in cystitis like dysuria(painful urination), fever and chills, but did not complain of back pain, or haematuria, hence it is likely that she is suffering from cystitis.

UTI occurs more frequently in woman as compared to men, due to the short urethra they have, allowing entry of bacteria into the urinary tract. The most common cause of UTI is Escherichia coli, a normal flora in the intestine and colon that enters and invades the urethra causing an infection. The second most likely bacteria that can cause UTI is Staphylococcus saprophyticus, as it usually infects woman in between the age of 20-40. Other microbes such as Klebsiella pneumoniae, Proteus mirabilis and Enterococcus species can also cause UTI, however, their occurrence is very low .

They are eliminated because:
a) Enterocoocus species usually occurs in patients who have undergone urinary tract surgery.
b) Proteus mirabilis often infect recurrent UTI patients that have structural abnormalities in their urinary system.
c) Klebsiella pneumoniae is involved in hospital-acquired infection and commonly infect immunocomprised individuals.

Most possible diagnosis: Escherichia coli and Staphylococcus saprophyticus
All the above characteristics were not observed in the patient and hence can be eliminated.
The two most likely cause of UTI are Escherichia coli and Staphylococcus saprophyticus.



Case Study 2
Patient: Female/29 years old
Signs and symptoms: Diarrhea
Suspected Diagnosis: Enterocolitis
Specimen collected: Stool

Types of enterocolitis:
1) Necrotizing enterocolitis
●Gastrointestinal disease that mostly affects premature infants, NEC involves infection and inflammation that causes destruction of the bowel intestine or part of the bowel.
● NEC typically occurs within the first 2 weeks of life, usually after milk feeding has begun

2) Autistic enterocolitis
●Autistic enterocolitis is a controversial term first used by British gastroenterologist Andrew Wakefield to describe a number of common clinical symptoms and signs which he contends are distinctive to autism.
● The existence of autistic enterocolitis is controversial, as the methodology of Wakefield's studies has been criticized and his results have not been replicated by other groups

3) Salmonella enterocolitis
● Most common type of food poisoning
● Infection in the lining of the small intestine caused by the bacteria Salmonella.
●Symptoms include diarrhea and abdominal pain

Most possible diagnosis: Salmonella enterocolitis
Reasons: Since necrotizing enterocolitis affects mainly infants but the patient is a 29-year-old female, it is highly unlikely that she is suffering from this disease. Moreover, it is not known to the medical technologist that the patient is suffering from autism. Hence, there is very low chance of her suffering from autism enterocolitis. The symptoms of salmonella enterocolitis include diarrhea which is one of the complaints as told by the female patient.



Case Study 3
Patient: Female/67 years old
Signs and symptoms: Fever, chills, bladder distension (bladder stretching); on indwelling catheter
Suspected Diagnosis: Urinary tract infection
Specimen collected: Urine

Indwelling catheters
Indwelling catheters avoid distension by emptying the bladder continuously into a bedside drainage collector. Individuals with indwelling catheters are encouraged to maintain a high fluid intake in order to prevent bacteria from accumulating and growing in the urine.

Possible agents:
● Many different Gram-negative organisms colonize urinary catheters, often becoming invasive infections.
●The most commonly isolated pathogens are Escherichia coli and Enterococcus spp.E.coli uses fimbriae to adhere to the urinary epithelium, thereby reducing the risk of being washed away.
● Infections caused by Proteus spp. are more likely in patients who have stones as Proteus spp. have urease activity that raises urinary pH, thus encouraging stone formation.
● Staphylococcus saprophyticus is a common isolate from sexually active females.
● Other intestinal bacteria, including Klebsiella pneumoniae (K.pneumoniae), Proteus mirabilis (P.mirabilis) , and Citrobacter.
●Others include Pseudomonas aeruginosa (P.aeruginosa), Enterobacter, and Serratia species, gram-positive organisms, including Enterococcus species, and S. saprophyticus .

Most possible diagnosis: Staphylococcus saprophyticus, Klebsiella pneumoniae, Proteus mirabilis and Enterococcus
UTI in this patient should be due to the presence of the catheter in the urethra. Hence these microbes might the possible reason.

Case Study 4
Patient: Male /68 years old
Signs and symptoms: fever, chills, excessive phlegm, breathing problems Suspected Diagnosis: Bronchitis
Specimen collected: Sputum

Information on Bronchitis
Inflammation of the mucous membrane in the lungs' bronchial passages
Narrowed bronchial passages shuts off the tiny airways in the lungs
Results in coughing spells, thick phlegm and breathlessness
Two forms: acute (lasts less than 6 weeks) and chronic (more than two years)

Acute bronchitis
●responsible for the hacking cough and phlegm production that sometimes accompany an upper respiratory infection
● In most cases the infection is viral in origin, but sometimes it's caused by bacteria
● very common among both children and adults

Chronic bronchitis
● a serious long-term disorder that often requires regular medical treatment

Possible agents
1) Adenovirus
● Non-enveloped double-stranded linear DNA
● Icosahedral nucleocapsid with a fiber protruding from each of the 12 vertices
●Causes bronchitis when it affects the lower respiratory tract

2) Bordetella
●Small, coccobacillary, encapsulated gram negative rod
● Restricted to the respiratory tract (negative blood culture)
●Isolated and grown on Border-Gengou agar

3)Parainfluenza virus
●Single stranded RNA negative-strand viruses

4) Streptococcus pneumoniae
● Gram positive lancet-shaped cocci
● Arranged in pairs or short chains
●Higher mortality in persons aged 65 and above

5) Chlamydia pneumoniae
●Obligate intracellular bacteria
●Require host cells for growth
● Causes upper and lower respiratory tract infections

Most possible microbes:
These microbes expressed similar symptoms as the patient in this case study. Hence, they are the most likely microbes to be causing this illness.


Case Study 5
Patient: Male /37 years old
Signs and symptoms: fever, Swelling around operation wound
Suspected Diagnosis: Wound Infection
Specimen collected: wound swab

Wound Infection caused by bacteria
● This is because swelling is one of the hallmarks of inflammation due to infection by either endogenous factors like tissue necrosis or exogenous factors like microorganism infections.
● Fever, on the other hand, is a common manifestation of infection and inflammation that is caused by many bacterial products eg endogenous or exogenous pyrogens.
● Most wound infections are caused by normal flora found on the skin/body.

Pathogens related to different surgical procedures/operations:

Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence are as follows:
● Staphylococcus aureus (20%)
● Coagulase-negative staphylococci (14%)
● Enterococci (12%)
● Escherichia coli (8%)
● Pseudomonas aeruginosa (8%)
● Enterobacter species (7%)
● Proteus mirabilis (3%)
● Klebsiella pneumoniae (3%)
● Other streptococci (3%)
● Candida albicans (3%)
● Group D streptococci (2%)
● Other gram-positive aerobes (2%)Bacteroides fragilis (2%)

Most possible microbes:
However, out of all the organisms, the most common bacteria involved in wound infection due to operation was found to be Staphylococcus aureus, which accounts for 17-20% of the cases reported. Out of these cases, 40-50% are due to MRSA (Methicillin-resistant Staphylococcus aureus).

Case Study 6
Patient: Female/37 years old
Signs and symptoms: Fever, pain during urination and virginal discharge
Suspected Diagnosis: Urinary tract infection
Specimen collected: Vaginal discharge

Possible agents:
1) Trichomoniasis
A sexually transmitted disease caused by the anaerobic, flagellated protozoa Trichomonas vaginalis.
Symptoms of Trichomoniasis include painful urination, fever, discharge greenish-yellow vaginal fluid, lower abdominal pain and discomfort during sexual intercourse.

2) Bacterial Vaginosis
It is caused by imbalance of bacteria flora in vagina. Usually, it is characteristic by the overgrowth of Gardnerella vaginalis and Gardneralla mobiluncus,.
Gardnerella bacteria is facultative anaerobic and gram-negative, while Mycoplasma hominis
It symptoms includes gray vaginal discharge and painful urination.

3) Vaginal Candidiasis
An infection caused by yeast, Candida albicans.
Its morphology appearance is normally single-celled.
Symptoms includes discomfort during urination and produce cottage cheese-like vaginal discharge or irritation in genital area

4)Gonorrhea
Another sexually transmitted disease caused by Neisseria gonorrhoeae, which is a gram-negative, cocci and aerobic bacteria.
Which produces symptoms like fever, yellowish discharge and urethritis.

5)Chlamydia
A sexually transmitted disease caused by gram-negative cocci and aerobic bacteria Chlamydia trachomatis.
Chlamydia trachomatis required a host organism to survive.
Patients with Chlamydia will experience symptoms like fever, abnormal discharge and painful urination.

Most possible microbes:
Since Gonorrhea, Trichomoniasis and Chlamydia expressed similar symptoms as the patient in this case study, they are the most likely microbes to be causing this illness.

References
1. http://www.mayoclinic.com
2. http://www.healthatoz.com
3. http://www.nlm.nih.gov/medlineplus/encyclopedia.html
4. http://en.wikipedia.org/wiki/Wiki