You answered the question incorrectly.

Gram stains are performed on positive blood culture bottles. Match the organism that
MOST closely resembles the description of the Gram stain morphology provided.

Your answers are on the left. The correct answers are on the right and highlighted.

Bacillus
Large, gram-positive rods with square ends in short chains
anthracis
Yersinia pestis Gram-negative rod resembling Enterobacteriaceae, demonstrates
bipolar staining
Francisella Very tiny, pale staining, gram-negative coccobacillus; often
tularensis difficult to see individual cells
Brucella Small, gram-negative coccobacilli that appear gram-positive due to
species retention of crystal violet stain; individual cells present

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Bacillus anthracis is a large, gram-positive rod with square or concave ends. Usually
in short chains in clinical specimens, it often forms long chains in culture material.
Central to sub-terminal, oval spores with NO significant swelling of the cell, are
usually NOT present, but their presence increases with the age of the culture.

Y. pestis is a gram-negative rod that can form short chains and resembles other
Enterobacteriaceae. Gram stains performed from blood culture or other liquid media
may show the characteristic bipolar staining, referred to as "safety-pin" morphology.

F. tularensis is a very tiny, gram-negative coccobacillus that is pale or weak staining.

Due to the small size, it is often difficult to see individual cells.

Brucella species are small, gram-negative coccobacilli that stain very faintly and tend
to retain crystal violet, especially in blood cultures. For this reason, they may initially
be identified as gram-positive. The organism is larger than F.tularensis and individual
cells are evident.

You answered the question incorrectly.

What is the BEST method for detection of Chlamydia trachomatis in cases of sexually
transmitted disease (STD)?

The correct answer is highlighted below

Nonculture EIA methods

Cerevical tissue culture
Culture of Thayer-Martin agar
 DNA-amplification techniques
Fluorescent phase microscopy

Feedback4

DNA amplification techniques, such as nucleic acid amplification tests (NAAT),

probe for the DNA of Chlamydia trachomatis. These tests are the most sensitive tests
available and PCR is one of the most common forms of this method.

You answered the question incorrectly.

The CAMP reaction is most helpful in the identification of beta hemolytic

streptococci, group B (shown in the photograph as the arrowhead-shaped zone of
hemolysis at the tip of the red arrow). A beta hemolytic gram positive bacillus that
produces the rectangular-shaped area of hemolysis as shown by the blue arrow in the
photograph is:

The correct answer is highlighted below

Bacillus cereus
Arcanobacterium (Corynebacterium)
Listeria monocytogenes
Gardnerella vaginalis

Feedback

All of the species of gram positive bacilli listed in this exercise are beta hemolytic.
However, the beta hemolysis of Gardnerella vaginalis is only demonstrated when
agar containing human blood is used. However, of all the species listed in this
exercise, only Listeria monocytogenes produces the rectangular-shaped zone of
accentuated hemolysis in the CAMP test. Because both group B, beta hemolytic
streptococci and L. monocytogenes can cause meningitis in neonates and young
children, the rectangular shaped positive CAMP reaction may be a helpful clue to the
correct identification in cases where the colonial morphology on primary isolation
medium and gram stain features are equivocal.

You answered the question correctly.

As a gram positive coccus

I've become a bit fancy,
Short chains and motile, plus
I carry the gene VanC.

The correct answer is highlighted below

Enterococcus faecium
Staphylococcus aureus
Enterococcus cassiloflavus
Streptococcus pneumoniae

Feedback

Enterococcus cassiloflavus is unique among the gram positive cocci (except for E.
gallinarum which has similar properties) of being motile and carrying an intrinsic
chromosomal mutation gene called Van C that confers low grade resistance to
vancomycin. In contrast, many strains of Enterococcus faecium have high level
vancomycin resistance through expression of an inducible, transposon-mediated gene,
called Van A. Resistance to vancomycin has not developed with Staphylococcus
aureus; rather, many strains have become methicillin resistant through expression of a
gene called MecA. Many strains of Streptococcus pneumoniae have developed
penicillin resistance via the alteration of penicillin binding proteins, a mechanism
similar to the ampicillin resistance expressed by many strains of Enterococcus
species.

Question Difficulty: Level 9

You answered the question incorrectly.

Which of the following species of Mycobacterium might be associated with
contamination of the hot water system in large institutions such as hospitals?

The correct answer is highlighted below

M. xenopi
M. ulcerans
M. marinum
M. haemophilum
M. tuberculosis

Feedback

The optimum growth temperature of M. xenopi is 42C, which enables it to survive

and replicate as an environmental contaminant in hot water systems. Human
infections caused by M. xenopi are very rare but have been reported. The majority of
clinically significant species grow optimally at 37C or lower.

Question Difficulty: Level 8

You answered the question correctly.

What is the one test result that is the most specific in establishing an identification of
Staphylococcus aureus?

The correct answer is highlighted below

A positive catalase test

Demonstrating the fermentation of mannitol
A strong positive tube coagulase test
Susceptibility to bacitracin

Feedback

The one test result that is the most specific in establishing an identification of
Staphylococcus aureus is a strong positive tube coagulase test.
 Question Difficulty: Level 5

You answered the question incorrectly.

What is the purpose of using alcohol in the gram stain procedure:

The correct answer is highlighted below

Fix all gram positive organisms

Decolorize all gram positive organisms
Decolorize all gram negative organisms
Fix all gram negative organisms

Feedback

The alcohol in the gram stain solution acts as a decolorizer which washes the stain
away from everything in the smear except the gram-positive organisms.

Question Difficulty: Level 4

You answered the question correctly.

Match type of hemolysis on the right with best description:

Your answers are on the left. The correct answers are on the right and highlighted.

Gamma hemolysis No visible effect on blood

Alpha hemolysis Green area around bacteria incomplete hemolysis
Beta hemolysis Clear area around bacteria complete hemolysis

Feedback

Alpha hemolysis- Green area around bacteria incomplete hemolysis

Beta hemolysis- Clear area around bacteria complete hemolysis

Gamma hemolysis- No visible effect on blood

 Question Difficulty: Level 4

You answered the question correctly.

A 67 year-old man was seen in the emergency room complaining of cough, fever, and
piercing right posterior chest pain. X-ray of the chest revealed consolidation of the
right middle lobe of the lung. A sputum culture grew the bacterial species shown in
the upper photograph. The lower photomicrograph illustrates a gram-stain of the
sputum specimen. The most likely cause of the pneumonia is:

The correct answer is highlighted below

Klebsiella pneumoniae
Enterococcus faecalis
Staphylococcus intermedius
Streptococcus pneumoniae

Feedback

The clinical setting of lobar pneumonia in an elderly patient is most likely associated
with Streptococcus pneumoniae. The mucoid, alpha hemolytic colonies seen in the
blood agar plate and the gram-positive diplococci seen in the sputum specimen are
virtually confirmatory. Enterococcus faecalis can produce a gram stain similar to that
illustrated; however, the colonies are not mucoid and lobar pneumonia by this species
would be less likely. Klebsiella pneumoniae can appear as mucoid colonies on blood
agar and can cause lobar pneumonia similar to that described; however, the bacterial
cells are gram negative and bacilli. Staphylococcus intermedius would more likely
cause a necrotizing bronchopneumonia, the colonies are not mucoid and the cocci
arrange in loose clusters or tetrads rather than pairs.

Question Difficulty: Level 5

You answered the question incorrectly.

The clinical Gram stain taken from an endocervix revealed many WBC's with both
intracellular and extracellular gram- negative diplococci. The specimen was plated
onto a Modified Thayer-Martin plate and incubated. Following incubation, colonies
resembling N. gonorrheae were inoculated into separate CTA tubes containing
glucose, lactose, sucrose and maltose. The fluorescent monoclonal antibody test was
positive as well as the CTA maltose and glucose tubes. What is the most appropriate
next step?

The correct answer is highlighted below

Issue a final report of N. meningitidis

Issue a final report of N. gonorrhoeae
Recheck the maltose tube with a known strain of N. gonorrhoeae
Request a new specimen

Feedback

Typically, N. gonorrhoeae will oxidize glucose, but not maltose. In this case, the
maltose tubes should be checked by running a "control" of a known N. gonorrhoeae
to ensure that the test process is functioning accurately.

Question Difficulty: Level 7

You answered the question correctly.

A process by which bacteria or other biological material are preserved through freeze
drying under vacuum is termed:

The correct answer is highlighted below

Pheresis
Desiccation
Osmosis
Lyophilization

Feedback

Lyophilization is an effective means of preserving biological materials such as

bacteria and serum for long term storage.

Question Difficulty: Level 5

You answered the question incorrectly.

How should the organisms that are indicated by the arrows be reported?

The correct answer is highlighted below

 Gram-negative organisms seen
Gram-negative cocci
Intracellular gram-negative cocci
Intracellular gram-negative diplococci

Feedback

The most complete report is "Intracellular gram-negative diplococci." It is important

to state that the organisms are located intracellularly. The arrangement in pairs also
offers more information than simply stating "cocci."

Question Difficulty: Level 5

You answered the question incorrectly.

Which of the following microscopic techniques is best suited for direct examination
of the infectious agent of syphilis?

The correct answer is highlighted below

Light microscopy
Phase microscopy
Darkfield microscopy
Electron microscopy

Feedback

Darkfield microscopy allows a lower limit of resolution than bright-field microscopy

which helps the tiny spirochetes to be seen in patient samples. In darkfield microscpy,
there is a dark background where directly transmitted light is excluded by a dark-field
condenser allowing only scattered light to be focused on the specimen. With dark-
field microscopy bacteria appear luminous against a dark background.

Question Difficulty: Level 4

 You answered the question correctly.

This is a catalase-positive, coagulase-negative gram-positive coccus isolated from a

urine specimen from a 20-year-old college student. The image below is a Mueller
Hinton plate streaked with a 0.5 MacFarland standardized inoculum and a 5
microgram disk of novobiocin after overnight incubation. What is the identification of
the isolate?

The correct answer is highlighted below

Staphylococcus epidermidis
Staphylococcus aureus
Staphylococcus saprophyticus
Staphylococcus lugdenensis

Feedback

Staphylococcus saprophyticus is the correct answer because this organism is resistant

to novobiocin. It is a common cause of urinary tract infections in young sexually
active females. The other organisms are susceptible to novobiocin and would have a
zone of inhibition 16 mm or larger.

Question Difficulty: Level 5

You answered the question correctly.

Which of the following is the most suitable specimen for the isolation of Bordetella
pertussis:

The correct answer is highlighted below

Nasopharyngeal swab
Bronchial washing
Blood
Throat swab

Feedback

Bordetella pertussis is a small aerobic gram-negative coccobacillus. It can best be

cultured using a nasopharyngeal aspirate collected in a soft rubber catheter or a fine-
tipped calcium aliginate or dacron swab. It must be promptly inoculated onto Regan-
Lowe charcoal agar, or traditional Bordet-Gengou media.

Question Difficulty: Level 6

You answered the question correctly.

Which of the following is a characteristic of Brucella species?

The correct answer is highlighted below

Oxidase negative
Catalase negative
Urea positive
Large, gram-negative rods

Feedback

Brucella species is urea positive. Additional characteristics include:

Oxidase positive
Catalase positive
Gram stain demonstrates very small, faintly staining gram-negative
coccobacilli that may stain gram-positive
Slow growing, convex, non-hemolytic, non-pigmented colonies
Any isolate demonstrating these features should be immediately referred to your
Laboratory Response Network (LRN) reference laboratory.

Question Difficulty: Level 7

You answered the question incorrectly.

Label each of the Kligler Iron Agar reactions shown in the photographs by the name
of the most likely associated bacterial species:Your answers are on the left. The
correct answers are on the right and highlighted.

Enterobacter cloacae A
Shigella sonnei B
Proteus mirabilis C
Burkholderia cepacia D

Feedback

Of the bacterial species listed in this exercise, Proteus mirabilis alone produces
hydrogen sulfide (H2S), and in sufficient quantities to completely blacken the deep of
the KIA tube, as seen in Image C. Burkholderia cepacia is one of the glucose non-
fermenters; therefore, produces no acid or color change in the KIA tube (Image D).
Enterobacter cloacae ferments both glucose and lactose; therefore, produces
sufficient acid to convert the entire KIA tube to a yellow color (Image A). Shigella
sonnei ferments glucose but does not ferment lactose (non-lactose fermenter).
Sufficient acid is produced in the more anaerobic deep of the tube from glucose
fermentation to produce a yellow color; however, the acid from glucose alone is not
sufficient to overcome the oxidation of the amino acids to amines in the slant of the
tube. Therefore the slant retains the alkaline pH and the red color (Image B).
 Question Difficulty: Level 8

any laboratory that analyzes microbes or refers specimens that have the potential to
contain microbial agents or toxins is a sentinel laboratory.

The correct answer is highlighted below

True
False

Feedback

Any laboratory that performs microbial analysis is by default a sentinel laboratory. A

laboratory that refers specimens that may contain microbial agents or toxins is also a
sentinel laboratory.

Based on the extent of service provided, sentinel laboratories are designated as basic
or advanced.

Question Difficulty: Level 5

You answered the question incorrectly.

Match the names of the Mycobacterium species listed with the appropriate bucket
indicating whether it is a photochromogen or a scotochromogen.

Your answers are on the left. The correct answers are on the right and highlighted.

Scotochromogen Mycobacterium scrofulaceum

Photochromogen Mycobacterium marinum
Photochromogen Mycobacterium kansasii
Scotochromogen Mycobacterium flavescens

Feedback
Mycobacterium scrofulaceum and Mycobacterium flavescens produce yellow colonies
when incubated in the dark; therefore, should be dropped in the "scotochromogen"
bucket. In contrast, Mycobacterium marinum and Mycobacterium kansasii are the
most commonly recovered mycobacterial species, the colonies of which become
pigmented only after exposure to light for some hours (photochromogens, Bucket A).

Question Difficulty: Level 7

You answered the question incorrectly.

Which one of the following is the INCORRECT match between organism and the
appropriate diagnostic procedure?

The correct answer is highlighted below

Trichinella spiralis - serologic testing

Cryptosporidium - modified acid-fast stain
Echinococcus granulosus - routine ova and parasite examination
Schistosoma haematobium - examination of urine sediment
Mycobacterium tuberculosis acid fast stain

Feedback

Since Echinococcus granulosus tends to form cysts in lung or liver tissue, diagnosis
usually requires ultrasound, CT, or MRI to detect the location of one or more brood
cysts. Diagnosis can also be confirmed by examining cyst tissue or contents for
evidence of the parasite. Finally, diagnosis can also be made through serologic exam
or skin testing.

Question Difficulty: Level 8

You answered the question correctly.

Which malaria infection is associated with massive hemolysis, blackwater fever, and
blockage of capillaries?
The correct answer is highlighted below

Plasmodium vivax
Plasmodium falciparum
Plasmodium ovale
Plasmodium malariae
both a & c

Feedback

The CDC states that untreated malaria can progress to severe forms that may be
rapidly (<24 hours) fatal, malaria should always be considered in patients who have a
history of exposure (mostly: past travel or residence in disease-endemic areas). The
most frequent symptoms include fever and chills, which can be accompanied by
headache, myalgias, arthralgias, weakness, vomiting, diarrhea, and others. The
clinical presentation can vary substantially depending on the infecting species, the
level of parasitemia, and the immune status of the patient. Infections caused by P.
falciparum can progress to severe, potentially fatal forms with central nervous system
involvement (cerebral malaria), acute renal failure, respiratory distress syndrome,
massive hemolysis causing severe anemia, blackwater fever, and blockage of
capillaries.

Question Difficulty: Level 6

You answered the question incorrectly.

Children of me should be wary,

A gliding, piercing, tooth fairy.

The correct answer is highlighted below

Eikenella corrodens
Actinobacillus actinomycetemcomitans
Capnocytophaga ochracea
Fusobacterium nucleatum

Feedback
The association of children, teeth and "gliding" (referring to the unique motility seen
on agar plates) all point to Capnocytophaga ochracea, one of the primary causes of
localized juvenile periodontitis, an aggressive dental disease that leads to destruction
of teeth and the underlying alveolar bone. A variety of factors lead to this progressive
disease, including the production of substances that inhibit neutrophil function,
proteolytic enzymes and penetration of the deeper tissues through its unique gliding
motility. Actinobacillus actinomycetemcomitans is also associated with periodontal
disease; however, in the context of this exercise is ruled out because it does not
demonstrate gliding motility. Eikenella corrodens is also an inhabitant of the oral
cavity and produces colonies that pit the agar; however, has not been incriminated in
dental disease and is not motile. Fusobacterium nucleatum is an anaerobe with gram
stain features similar to Capnocytophaga, but in contrast as the propensity, along with
species of spirochetes, to cause gingivitis (trench mouth), but not periodontitis.

Question Difficulty: Level 8

You answered the question incorrectly.

Key characteristics by which Klebsiellapneumoniae can be suspected when an

unknown member of the Enterobacteriaceae is recovered in primary culture include:

The correct answers are highlighted below

Indole production
Absence of motility
Failure to decarboxylate ornithine
Positive phenylalanine deaminase

Feedback

Klebsiellapneumoniae is characteristically nonmotile, in contrast to other members of

the Klebsiella, Enterobacter, Hafnia, Serratia group which are all motile. Also, a key
reaction for the identification of Klebsiellapneumoniae in the API profile of tests is a
negative ornithine decarboxylase, as most other members of this group produce a
positive reaction. The indole reaction is not discriminatory for Klebsiella pneumoniae.
A positive phenylalanine deaminase reaction is most helpful in distinguishing Proteus
species and Providencia species from other members of the Enterobacteriaceae, and
has no discriminatory value in distinguishing Klebsiellapneumoniae.

Question Difficulty: Level 8

 You answered the question correctly.

Watch the tube effervesce,

As I turn the milk into a mess.

The correct answer is highlighted below

Pseudomonas aeruginosa
Clostridium perfringens
Enterobacter aerogenes
Haemophilus aphrophilus

Feedback

Each of the species listed in this exercise produce gas from glucose; however, only
Clostridium perfringens, with its intense proteolytic activity, produces the stormy
fermentation seen in this photograph. Although this test is not performed with any
frequency in clinical laboratories, in past times it was a valuable characteristic
separating C. perfringens from other bacterial species.

Question Difficulty: Level 4

You answered the question incorrectly.

Which of the following streptococcus exhibits a positive bile solubility test:

The correct answer is highlighted below

S. pyogenes
S. pneumoniae
S. agalactiae
S. mutans

Feedback

Streptococcus pneumoniae colonies dissolve with the additon of sodium deoxycholate

(positive bile sensitivity test) and are sensitive to Optochin- unlike other species of
Streptococci.

Question Difficulty: Level 5

You answered the question correctly.

Which of these nitrogenous bases is present in deoxyribonucleic acid (DNA), but not
in ribonucleic acid (RNA)?

The correct answer is highlighted below

Guanine
Cytosine
Adenine
Thymine

Feedback

Thymine is present in DNA, but not in RNA. Uracil is present in RNA, but not in
DNA.

Question Difficulty: Level 5

 You answered the question incorrectly.

A 30 year old laboratory worker doing extensive research on laboratory mice

developed sudden onset of fever, chills, headache and muscle aches. He remembered
being bitten by one of the mice about a week previously, although the skin wound
healed without incidence. The gram stain preparation illustrated in the
photomicrograph is representative of the organism recovered from blood cultures.

The correct answer is highlighted below

Yersinia pestis
Erysipelothrix rhusiopathiae
Streptobacillus moniliformis
Anaerobiospirillum succinoproducans

Feedback

A history of the sudden onset of fever, headache and muscle aches following the bite
of a rat or mouse is class for "rat bite fever", also known as "Haverhill fever", named
after the Massachusetts town where an outbreak occurred in the early 1970's. This
infection is caused by Streptobacillus moniliformis, a fastidious, pleomorphic, gram
negative bacillus the cells of which may appear filamentous, bulbous or coiled. The
gram stain shown in this exercise is consistent. Yersinia pestis and Erysipelothrix
rhusiopathiae may result in septicemia following the bite of rats, mice and other
rodents; however, the former produces short, coccobacilli on gram stain and the latter
gram positive bacilli. The bacterial cells of Anaerobispirillum succinoproducans may
also produce elongated, pleomorphic filamentous cells in gram stains;however, appear
tufted as they characteristically have polar flagellae. This bacterial species rarely
causes human infection and is not related to animal bites.

Question Difficulty: Level 8

 You answered the question incorrectly.

Match the names of each of the bacterial species listed into Bucket A if it tends to be
antibiotic resistant and into Bucket B if it tends to be susceptible.

Your answers are on the left. The correct answers are on the right and highlighted.

Bucket A Nocardia farcinica

Bucket A Corynebacterium ureolytica
Bucket B Bacillus anthracis
Bucket B Rhodococcus equii

Feedback

Antibiotic resistance to erythromycin, cefotaxime and tobramycin in specific are

valuable characteristics in differentiating Nocardia farcinica from other members of
the N. asteroides complex, which are susceptible to these antibiotics. Among the
Corynebacterium species, C. ureolyticum and C. jeikeium are separated out because of
their tendency to be resistant to a variety of commonly used antibacterial agents.
Other Corynebacterium species, including the closely related Rhodococcus equii, are
susceptible to most antibiotics. Although antibiotic susceptibility profiles vary within
the genus Bacillus, B. anthracis in particular remains susceptible to penicillin and
most other beta lactam antibiotics.

Question Difficulty: Level 9

You answered the question incorrectly.

If a Brucella species is suspected in a blood culture it should be held for a MINIMUM

of how many days?

The correct answer is highlighted below

5
7
14
21
30
Feedback

If a Brucella species is suspected in a blood culture it should be held for a MINIMUM

of 30 days. Brucella spp. is highly infectious and presents an infection risk to
laboratory workers. It is suggested that laboratories should hold cultures for 30 days,
as Brucellais a slow-grower, and use great caution to avoid exposure within the
laboratory by aerosol.

Question Difficulty: Level 9

You answered the question incorrectly.

Motility is a key initial assessment in the presumptive identification of the

nonfermentative gram negative bacilli. Place each of the bacterial species into Bucket
A if it is motile and into Bucket B if it is nonmotile.

Your answers are on the left. The correct answers are on the right and highlighted.

Motile Burkholderia cepacia

Motile Alcaligenes faecalis (odorans)
Nonmotile Moraxella osloensis
Nonmotile Chryseobacterium meningosepticum

Feedback

All members of the genus Burkholderia (formerly in the genus Pseudomonas) are
motile via polar flagellae. All members of the genus Alcaligenes are motile via
peritrichous flagellae. All members of the genus Moraxella are non motile, as are the
two members of the genus Chryseobacterium (recently transferred from the genus
Flavobacterium).

Question Difficulty: Level 9

You answered the question correctly.

The type of sporulation illustrated in this photomicrograph of a dematiaceous fungus
is:

The correct answer is highlighted below

Rhinocladiella
Acrotheca
Cladosporium
Phialophora

Feedback

The production of dark, elliptical conidia in branching chains with the conidia
separated by a delicate black scar or dysjunctor is characteristic of the cladosporium
type sporulation.

In rhinocladiella type sporulation, the conidia are borne from either side of a straight
conidiophore in a picket fence arrangement. Acrotheca type sporulation is somewhat
similar to the cladosporium type except that the chains are quite short and the conidia
are derived circumferentially from the hyphae, much as the hooks on a hat rack.

Phialophora type sporulation involves the production of vase-like phialides with a

distinct mouth from which spherical or slightly elliptical conidia are produced in
clusters.

Question Difficulty: Level 6

You answered the question incorrectly.

A sputum sample from a patient with pulmonary abscesses is received in the
laboratory, and after several days of incubation the following are noted:

Yellow, irregular colonies grow on BAP under aerobic conditions.

Acid-fast stain shows that the organisms are partially acid-fast.

Which of the following organisms should be suspected?

The correct answer is highlighted below

Nocardia asteroides
Streptococcus pneumoniae
Actinomyces israelii
Actinomadura madurae
Mycobacterium avium

Feedback

Nocardia stain partially acid-fast which is the biggest clue to the answer in this case.
In pulmonary nocardiosis, the lesions contain N. asteroides though the abscesses in
the form of tangled, branching filaments. N. asteroides typically shows a colony
morphology of yellow, irregular colonies that grow on BAP under aerobic conditions.

Question Difficulty: Level 7

You answered the question incorrectly.

Match the names of each of the bacterial species with the most likely appearance of
colonies on the 5% sheep blood agar plates shown in the photographs. As added clues,
the colonies in Image B produce the odor of blue tortilla chips; the odor of the
colonies in Image D have the odor of freshly peeled apples.

Your answers are on the left. The correct answers are on the right and highlighted.

Chrysobacterium (Flavobacterium) meningosepticum A

Pseudomonas aeruginosa B
Pseudomonas stutzeri C
Alcaligenes faecalis (odorans) D

Feedback

Pseudomonas stutzeri produces dry, wrinkled, gray-yellow colonies on blood agar

(Image C). The colonies of Chryseobacterium (Flavobacterium) meningosepticum are
typically yellow, as indicated by the pigment on the tip of the cotton swab after one of
the colonies had been touched (Image A). P.stutzeri also produces yellow colonies,
but they are not smooth. The species, formerly called Alcaligenes odorans (Image D),
produces dirty gray colonies with a green discoloration on blood agar, as seen in
Image D, with a sweet odor of peeled apples. P. aeruginosa also produces green-
pigmented colonies, as seen to less degree in Image B; however, has an odor
described as grape like or similar to blue tortilla chips.

Question Difficulty: Level 9

You answered the question incorrectly.

The blue color seen in the Simmon's citrate agar slant to the right tube shown in this
photograph, indicating a positive reaction, results from:

The correct answer is highlighted below

Reduction of citric acid to sodium citrate

Assimilation of carbon from sodium citrate
Production of ammonia from ammonium phosphate
Formation of amines from peptones in the medium

Feedback

Simmons citrate medium contains inorganic sodium citrate as a source for carbon, and
ammonium phosphate, which serves both as a buffer and as a source of nitrogen.
Bacterial species that can extract carbon from the sodium citrate can also extract
nitrogen from the ammonium phosphate, resulting in release of ammonia (NH3),
causing a rise in pH of the medium and conversion of the bromthymol indicator from
green to blue. Although the utilization of carbon from sodium citrate may reduce the
amount of acid ions making the medium more alkaline, this pH shift is insufficient to
convert the indicator. Simmons citrate medium is devoid of all organic sources of
carbon, including peptones.

Question Difficulty: Level 9

You answered the question correctly.

Which of the following media would you use to isolate Francisella tularensis:

The correct answer is highlighted below

Sheep-blood agar
Lowenstein-Jensen media
Bordet-Gengou media
Cysteine-blood agar

Feedback

Although cysteine-blood agar was traditionally used, F. tularensis will also grow on
commercially available Thayer-Martin and chocolate agar which have been enriched
with supplemental nutrients.
 Question Difficulty: Level 6

You answered the question correctly.

Arrange the names of the bacterial species listed in ascending order of least
pathogenic to most virulent based on the severity of the human infections they may
cause.

Your answers are on the left. The correct answers are on the right and highlighted.

First Corynebacterium cystitidis

Fourth Bacillus anthracis
Third Listeria monocytogenes
Second Nocardia brasiliensis

Feedback

Corynebacterium cystitidis, one of the non-lipid requiring corynebacteria that most

commonly cause infections in cows, is of low virulence as no human infections have
been reported. Nocardia brasiliensis causes subcutaneous infections that tend to
remain localized to the skin and only rarely is incriminated in disseminated infection.
One might argue whether L. monocytogenes or B. anthracis is most virulent.
Obviously, an immunosuppressed person with listeria meningitis is in serious trouble;
and, mortality rates between 23% and 70% have been cited. However, B. anthracis is
one of the most virulent of all bacterial species with which humans come in contact
and should be placed as the most pathogenic of the bacterial species listed in this
exercise. Persons with cutaneous anthrax may have a 20% chance of fatality if
untreated; virtually 100% of those with inhalation anthrax will succumb to the
infection.

Question Difficulty: Level 8

You answered the question incorrectly.

Match the name of each of the bacterial species listed with its most likely associated
clinical condition.

Your answers are on the left. The correct answers are on the right and highlighted.
 Enterobacter sakasakii Neonatal meningitis
Morganella morganii Alkaline cysitits
Klebsiella osaenae Atrophic rhinitis
Yersinia pseudotuberculosis Mesenteric adenitis

Feedback

Klebsiella ozaenae, along with the closely related K. rhinoscleromatis, cause

infections primarily limited to the nasal passages. K. ozaenae produces an offensive
smelling, purulent infection of the nasal mucous membrane called ozena. Of the
species listed in this exercise, E. sakasakii is most commonly associated with neonatal
meningitis (Muytjens, et al, analysis of 8 cases of neonatal meningitis and sepsis, J
Clin Microbiol 18:115-120, 1983; and, Biering et al, report of 3 cases of neonatal
meningitis related to contaminated powdered milk, J Clin Microbiol 27:2054-2056,
1989). Y. pseudotuberculosis is one of the bacterial species recovered in cases of
mesenteric adenitis in children, a disease simulating acute appendicitis. Morganella
morganii is a bacterial species associated with urinary tract infections. The active
urease activity results in a markedly alkaline urine and ammonium phosphate
crystaluria.

Question Difficulty: Level 9

You answered the question incorrectly.

A yellow pigmented nocardioform bacterial species was recovered from repeated sets
of blood cultures. It was non acid fast, motile and the filamentous mycelium broke up
into fragments as the culture matured. The most likely identification is:

The correct answer is highlighted below

Rhodococcus equii
Oerskovia turbata
Actinomyces pyogenes
Propionibacterium acnes

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Key characteristics mentioned in the question are the yellow pigmented colonies and
positive motility. Of the actinomycetes and nocardioform bacteria, only members of
the Oerskovia and Dermatophilus genera are motile. The colonies of Rhodococcus
equii are not yellow, rather are salmon pink in hue. Although Actinomyces pyogenes
has been classified in the genus Actinomyces, the bacterial cells are more rod shaped
and diphtheroidal in arrangement, and do not form filaments that become fragmented.
Also, the colonies are not pigmented. Similarly, the bacterial cells of
Propioniobacterium acnes are rod shaped and diphtheroidal in arrangement and the
colonies are not yellow pigmented.

Question Difficulty: Level 9

You answered the question incorrectly.

Asaccharolytic use of glucose would be indicated by which reaction in OF glucose

tubes:

The correct answer is highlighted below

Yellow at the top of the open tube, closed tube green

Green in both tubes with a little blue at the top of the open tube
Yellow in both tubes
Green at the top of the open tube, yellow in the bottom of the open tube and
yellow in the closed tube

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B is the correct answer because asaccharolytic describes an organism that cannot

utilize glucose either oxidatively or via fermentation; therefore, there would be no
color change (stays green). When glucose is utilized in OF tubes, a high concentration
of acid produced during fermentation or oxidation will turn the bromthymol blue
indicator in OF media from green to yellow.

Question Difficulty: Level 8

You answered the question correctly.

Which of the following Mycobacterium species is associated closely with HIV/AIDS

patient infections?

The correct answer is highlighted below

 M. ulcerans
M. avium-intracellulare complex
M. gordonae
M. bovis

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The Mycobacterium avium-intracellulare complex is closely associated with

infections in immunocompromised HIV/AIDS patients. Infections in this population
with M. avium-intracellulare complex can be fatal.

Question Difficulty: Level 5

You answered the question incorrectly.

The well circumscribed, ulcerating pustule illustrated in the upper photograph evolved
over 8 days following direct contact with raw animal hides that had been shipped in
from Central Asia. The lesion began as a small papule, which progressively enlarged,
ultimately ulcerated and became covered centrally with a black eschar. The lower
photomicrograph is a gram stain prepared from a colony that grew within 48 hours on
blood agar. The most likely agent of this infection is:

The correct answer is highlighted below

Bacillus anthracis ("malignant pustule")

 Erysipelothrix rhusiopathiae (erysipeloid)
Francisella tularensis
Streptococcus pyogenes (pyoderma)

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The photograph illustrates a "malignant pustule" characteristic of cutaneous anthrax

infection. Such papules and pustules develop at the site of skin penetration of bacterial
spores, most commonly found in wool, hair, hides and animal bones that are shipped
from countries where the disease is endemic. The lower photograph demonstrates
spore-forming, "boxcar-shaped" gram positive bacilli characteristic of Bacillus
anthracis. Although a similar appearing pustule may be produced in some stage of
evolution by each of the other bacterial species listed in this exercise, only B.
anthracis produces bacterial cells with spores. F. tularensis is a short, gram negative
coccobacillus, E. rhusiopathiae is a non spore forming gram positive bacillus and
Streptococcus pyogenes is a gram positive coccus in chains.

Question Difficulty: Level 4

You answered the question correctly.

Bacterial colonies often emit distinct odors associated with foods. Match the names of
each of the foods listed with its associated bacterial species.

Your answers are on the left. The correct answers are on the right and highlighted.

Grapes Pseudomonas aeruginosa

Popcorn CDC group EF4
Peeled apples Alcaligenes faecalis (odorans)
Butterscotch Streptococcus milleri

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A colony that produces a distinct fruity odor, often likened to freshly peeled apples, is
characteristic of Alcaligenes faecalis (odorans) or Flavobacterium odoratum. The
tiny, minute colonies of Streptococcus milleri can be presumptively identified if a
distinct butterscotch odor is detected. The odor of Pseudomonas aeruginosa is most
commonly referred to as grape-like. The smell of popcorn is most indicative of CDC
group EF4.
 Question Difficulty: Level 7

You answered the question incorrectly.

Which one of the following is NOT usually associated with Group A Beta Strep?

The correct answer is highlighted below

Scalded Skin Syndrome

Glomerular nephritis
Heart muscle damage
Rheumatic fever
Scarlet fever

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Group A Beta Strep is most commonly associated with glomerular nephritis, heart
muscle damage, Rheumatic fever, Scarlet fever. Other types of infections are also
possible, such as bacteremia, cellulitis, toxic shock syndrome,etc. but are much less
common than those listed above. Scaled Skin Syndrome is usually caused by
Staphylococcal infections as opposed to Group A Beta Strep.

Question Difficulty: Level 7

You answered the question correctly.

Bordet-Gengou potato infusion agar has been the time-honored medium for the
recovery of which one of the following organisms?

The correct answer is highlighted below

Bordetella pertussis
Corynebacterium diphtheriae
 Haemophilus influenzae
Moraxella catarrhalis
Neisseria meningitidis

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Bordet-Gengou potato infusion agar has been the time-honored medium for the
recovery of Bordetella pertussis. This bacterium requires media supplemented with
charcoal, blood (20%), potato (starch) to absorb toxic substances in agar.

Question Difficulty: Level 4

You answered the question incorrectly.

The mechanism by which certain strains of Enterococcus species have developed

resistance to the synergistic combination of aminoglycoside and beta-lactam
antibiotics is:

The correct answer is highlighted below

Alteration of penicillin binding proteins

Beta lactamase activity against the beta-lactam moiety
High level gentamicin resistance
Efflux of antibiotics from the bacterial cell

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Enterococci have an intrinsic resistance to aminoglycoside antibiotics because they

are not able to efficiently cross the bacterial cell wall. Therefore, the addition of a beta
lactam antibiotic such as penicillin has the effect of making the cell wall permeable to
the aminoglycoside, that can then gain access to its ribosomal binding site. High level
synergy resistance develops when the bacterium alters the ribosomal binding site so
that even high intracellular concentrations of aminoglycoside are ineffective.
Alteration of penicillin binding proteins is the mechanism by which S. pneumoniae
has developed resistance to penicillin. Only a low percentage of strains of
Enterococcus species produce beta lactamases, which do not affect the synergy
resistance phenomenon. Active transport or efflux of antibiotics from the bacterial cell
is a resistance mechanism active against tetracyclines and macrolides.
 Question Difficulty: Level 9

You answered the question incorrectly.

It is common practice to perform a spot indole test on all swarming Proteus species
recovered from wound infections. The rationale for this practice is:

The correct answer is highlighted below

Indole negative strains are less virulent

Indole positive strains tend to be penicillin resistant
Indole positive strains are more likely to cause septicemia
Unfounded, as there is no clinical relevance

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It is important in the selection of empiric antibiotic therapy of wound infections

caused by Proteus species to know if the indole positive Proteus vulgaris is involved
as it tends to be resistant to penicillins and cephalosporins, necessitating the use of
other antibiotics. Both indole positive and negative strains are of essentially equal
virulence and neither has any inordinate predisposition to invade the blood stream and
cause septicemia.

Question Difficulty: Level 6

You answered the question incorrectly.

The beta hemolysis seen around the opaque, flat, spreading colonies illustrated in this
photograph of a 5% blood agar plate is helpful in differentiating Bacillus cereus
(hemolytic) from Bacillus anthracis (not hemolytic). Each of the following
characteristics is also helpful in differentiating these two species except:

The correct answer is highlighted below

 Motility
Hydrolysis of gelatin
Lecithinase production
Fermentation of salicin

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Bacillus cereus is motile, hydrolyzes gelatin and produces acid fermentatively from
salicin. Bacillus anthracis is negative for each of these, which therefore become
important differentiating characteristics between these two species. Of the Bacillus
species commonly encountered in clinical laboratories, only B. cereus, B. anthracis
and B. mycoides produce lecithinase; therefore, this is not a distinguishing
characteristic between these three species and thus is the correct answer by exclusion
in this exercise.

Question Difficulty: Level 7

You answered the question incorrectly.

A cell wall deficient bacterium that commonly causes atypical or "walking

pneumonia" is:

The correct answer is highlighted below

Mycoplasma pneumoniae
Pneumocystis carinii
Mycobacterium xenopi
Bifidobacterium dentium

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Patients with mycoplasma pneumonia have symptoms of a "cold" or the flu, yet are
not sufficiently ill to discontinue their activities. Thus, the terms "atypical" and
"walking pneumonia" have been used to refer to this form of infection. All of the
other bacterial species included in this exercise possess cell walls; therefore, on this
basis are ruled out as correct responses. The pneumonia caused by Legionella
pneumonia is lobar in type, often bilateral, and generally accompanied by high fever,
chills, cough, sputum production, chest pain and a general run down feeling.
Complications may include liver function abnormalities, watery diarrhea, and, in
severe cases, somnolence, delirium and confusion, potentially leading to death.
Mycobacterium xenopi pulmonary infection resembles classic tuberculosis, with
patients complaining of low grade fever, night sweats, persistent cough and pleuritic
chest pain. Bifidobacterium dentium, along with many other anaerobes causing
pulmonary disease, are associated with aspiration pneumonia which tends to be
necrotizing and debilitating.

Question Difficulty: Level 3