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MOD-Exam 3 > Bacteria: Gram Negative and more > Flashcards

Bacteria: Gram Negative and more Flashcards

1
Q

Which of the following virulence factors of Neisseria meningitidis is antigenic and has many serogroups, in which the most common causers of meningitis often possess serogroups A, B, and C?

A. Capsule

B. IgA1 protease

C. LPS

D. Pili

A

Capsule

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2
Q

Which virulence factor of Neisseria mengitidis causes blood vessel rupture that leads to petechiae on the skin, and causes potential damage to adrenal glands?

A. Capsule

B. IgA1 protease

C. LPS

D. Pili

A

LPS

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3
Q

What virulence factor is only found in Neisseria meningitidis? Bonus: what does this virulence factor do?

A. Capsule

B. IgA1 protease

C. LPS

D. Pili

A

IgA1 proteases

IgA1 protease cleaves IgA in half

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4
Q

What virulence factor of Neisseria mengitidis allows the pathogen to attach to nasopharyngeal cells and undergo antigenic variation that aids in preventing its detection by immune cells?

A. Capsule

B. IgA1 protease

C. LPS

D. Pili

A

Pilli

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5
Q

All of the following groups are high risk for infection by Neisseria mengitidis, EXCEPT?

A. Infants aged 6 months to 2 years old

B. Children aged 8-14

C. Army recruits

D. College freshman

A

Children aged 8-14

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6
Q

Which of the following is the most common form of meningococcal disease?

A. Meningococcemia

B. Fulminant Meningococcemia (WAterhouse-Friderichsen Syndrome)

C. Meningitis

D. None of the above

A

Meningitis

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7
Q

Which of the following meningococcal diseases can lead to 2 of the other diseases listed below?

A. Meningococcemia

B. Fulminant Meningococcemia (WAterhouse-Friderichsen Syndrome)

C. Meningitis

D. None of the above

A

Meningococcemia

NOTE:

Meningococcemia can lead to Fulminant mengococcemia and/or meningitis

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8
Q

Which of the following meningococcal diseases is essentially septic shock?

A. Meningococcemia

B. Fulminant Meningococcemia (WAterhouse-Friderichsen Syndrome)

C. Meningitis

D. None of the above

A

Fulminant Meningococcemia (WAterhouse-Friderichsen Syndrome)

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9
Q

What are the 3 bacteria responsible for most meningitis acquired by an infant LESs than 3 months old?

A

Listeria

E. coli

Group B Strep

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10
Q

The classic medium used for testing for N. meningitidis is called Thayer-Martin VCN that is a chocolate agar with antibiotics. The V stands for vancomycin which causes what affect?

A. Destruction of all gram negative bacteria except for Neisseria

B. Destruction of all gram positive bacteria

C. Destruction of all fungi

D. All of the above

A

Destruction of all gram positive bacteria

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11
Q

The classic medium used for testing for N. meningitidis is called Thayer-Martin VCN that is a chocolate agar with antibiotics. The C stands for colistin which causes what affect?

A. Destruction of all gram negative bacteria except for Neisseria

B. Destruction of all gram positive bacteria

C. Destruction of all fungi

D. All of the above

A

Destruction of all gram negative bacteria except for Neisseria

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12
Q

The classic medium used for testing for N. meningitidis is called Thayer-Martin VCN that is a chocolate agar with antibiotics. The N stands for nystatin which causes what affect?

A. Destruction of all gram negative bacteria except for Neisseria

B. Destruction of all gram positive bacteria

C. Destruction of all fungi

D. All of the above

A

Destruction of all fungi

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13
Q

What is the second most common STI?

What gram negative bacteria is responsible for causing this STI?

A

What is the second most common STI?

gonorrheae

What gram negative bacteria is responsible for causing this STI?

gonococcus (Neisseria gonorrhoeae)

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14
Q

Which of the following is true of ALL of the Gonococcus virulence factors Pili, PorA, and PorB, and Opa proteins overall? Bonus: For the incorrect options, highlight which virulence factor the trait is specific for.

A. They destroy the cilia on neighboring cells

B. They prevent phagocytosis

C. They promote invasion into the host’s epithelial cells

D. Allow gonococcus to bind to non-ciliated epithelial cells

A
  • A. They destroy the cilia on neighboring cells (LPS endotoxin)*
  • B. They prevent phagocytosis (Pili)*
  • C. They promote invasion into the host’s epithelial cells (Opa proteins, PorA, and Por B)*

D. Allow gonococcus to bind to non-ciliated epithelial cells

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15
Q

PID can occur when a gonococcal infection of the cervix progresses and infects the uterus, fallopian tubes, and/or endometrium. IUD’s increase risk of cervical gonococcal infection occurence, and 50% of cases of PID occur within one week of onset of menses. What can you tell me is the greatest complication of PID?

A. Ectopic pregnancy

B. Absecess

C. Infertility

D. Peritonitis

E. Peri-hepatitis

A

Infertility

NOTE:

The other listed options are all potential complications of PID

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16
Q

What are two possible disease occurances that may develop in men or women with gonococcal infection that goes untreated?

A

Bacteremia (rare)

Septic Arthritis

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17
Q

T/F: the HACEK group of bacteria is a slow growing gram negative pathogenic group known to cause endocarditis and includes Kingella

A

True

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18
Q

Moraxella Catarrhalis is a gram negative bacteria that’s also known as Branhamella catarrhalis. This pathogen causes what 2 major diseases? What groups mostly develop the diseases caused by this pathogen?

A

Otitis media

children under 3

Upper respiratory infection

elderly and people with COPD

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19
Q

Though the enterics are a large group of gram negative bacteria for which there are many groups. What are the 4 main groups?

A

Enterobacteriaeceae

Vibrionaceae

Pseudomonadaceae

Bacteriodaceae

The Enterics: Enter Vibrating Pseudo Bacteria

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20
Q

How are coliforms useful for determining if fecal matter is contaminating a water source?

What is a common coliform?

A

How are coliforms useful for determining if fecal matter is contaminating a water source?

Coliforms are normal bacterial inhabitants of the intestine, and their presence in a water source indicates that intestinal contents (poop) are present in that system

What is a common coliform?

E. coli

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21
Q

Which of the following enterics are able to ferment lactose, converting it to acid and gas?

A. Shigella

B. Salmonella

C. E. coli and most of the enterobactericeae

D. Pseudomonas aeruginosa

A

E. coli and most of the enterobactericeae

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22
Q

In an EMB agar (eosine methyelene blue) E. coli turns which of the following colors?

A. Deep purple to black

B. Metallic green sheen

C. Pink-purple

D. None of the above

A

Metallic green sheen

NOTE:

EMB turns lactose fermenters deep purple black

MacConkey turns lactose fermenters into a pink-purple coloration

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23
Q

Gram negative, lactose fermenting bacteria would likley appear what color when plated on a MacConkey agar?

A. Deep purple to black

B. Metallic green sheen

C. Pink-purple

D. None of the above

A

Pink-purple

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24
Q

Enterics have 3 major surface antigens that all vary slightly between each bacterium. Which of the following Ags is not found on Shigella and thus is why it is not motile and lacks flagella unlike Salmonella?

A. O antigen

B. K antigen

C. H antigen

A

H antigen

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25
Q

Enterics have 3 major surface antigens that all vary slightly between each bacterium. Which of the following Ags is the outer most antigen?

A. O antigen

B. K antigen

C. H antigen

A

O antigen

NOTE:

O antigen is the Outer most antigen

K antigen forms the Kapsule

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26
Q

Which of the following is likely the cause of watery diarrhea without system symptoms?

A. Enterics do not invade the cell but bind and release enterotoxins; exemplified by E. coli and vibrio cholera

B. Enterics invade the intestinal epithelial cells throughutilization of their virulence factors; exemplified by E. coli, Salmonella, and shigella

C. Enterics invade lymph nodes and the bloodstream; exemplified by Salmonella, Yersinia, and Campylobacter jejuni

D. None of the above

A

A. Enterics do not invade the cell but bind and release enterotoxins; exemplified by E. coli and vibrio cholera

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27
Q

Which of the following is likely the cause of diahrrea containing WBCs and RBCs, followed by system reaction where we see fever, headache, and increased WBCs (left shift?)?

A. Enterics do not invade the cell but bind and release enterotoxins; exemplified by E. coli and vibrio cholera

B. Enterics invade the intestinal epithelial cells throughutilization of their virulence factors; exemplified by E. coli, Salmonella, and shigella

C. Enterics invade lymph nodes and the bloodstream; exemplified by Salmonella, Yersinia, and Campylobacter jejuni

D. None of the above

A

C. Enterics invade lymph nodes and the bloodstream; exemplified by Salmonella, Yersinia, and Campylobacter jejuni

NOTE:

When enterics just invade intestinal epithelial cells we will likely just find WBCs in the stool

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28
Q

Based on the virulence factors of E. Coli, it can cause diarrhea that resembles infection from what 2 other enterics?

A

Vibrio cholera

Shigella

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29
Q

Enterotoxigenic E. Coli (ETEC) causes “travelers diarrhea” where the diarrhea is watery due to inhibited uptake of NaCl by intestinal cells. ETEC is caused by which of the following mechanisms/virulence factors?

A.Pili releases shiga-like toxin which mimics the MOA of Shiga toxin

B. Pili releases heat labile (LT) and heat stable (ST) toxin

C. Pili releases virulence factor that is encoded by the same plasmid that Shigella contains

D. None of the above

A

B. Pili releases heat labile (LT) and heat stable (ST) toxin

See ETEC and think about the factors with a T in them, LT and ST

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30
Q

The release of Shiga-like toxin from Enterohemorrhagic E. Coli (EHEC) infection would cause or most likely lead to all of the following results, EXCEPT?

A. Bloody diarrhea accompanied with hemorrhagic colitis

B. Bloody diarrhea that contains most WBCs

C. Anemia, thrombocytopenia, and renal failure (Hemolytic Uremic Syndrome)

D. Stop eating hamburger meat served at fast-food chains

A

B. Bloody diarrhea that contains most WBCs

B. is caused by Enteroinvasive E. Coli (EIEC)

31
Q

What is absolutely known if we see the development of cystitis or pyelonephritis caused by E. Coli?

A. E. coli acquired a pili virulence factor that allowed it to travel up the urethra

A

E. coli acquired a pili virulence factor that allowed it to travel up the urethra

32
Q

Which of the following bacteria is the most common cause of gram-negative sepsis?

A. Salmonella

B. E. Coli

C. Neisseria gonorrhea

D. Klebsiella pneumoniae

A

E. Coli

NOTE:

Klebsiella pneumoniae is the 2nd most common cause of sepsis

33
Q

You are treating a hospitalized patient who’s been suffering from alcoholism for a long time. They’ve recently developed pneumonia and have been coughing up a bloody sputum that looks like “red currant jelly”. Which is most likely true of the pathogen which caused this?

A. The red currant jelly sputum is the same color as the pathogens O antigen

B. The pathogen does not possess an H antigen and is thus non-motile

C. The pathogen has a high mortality rate despite antibiotics being available for treatment

D. The pathogen is liekly Klebsiella pneumoniae

E. All of the above are correct

A

All of the above are correct

O**h my it looks like that alcoholic was **Kleb**bed into a **red jelly

34
Q

Which of the following members of the Enterobacteriaceae family is highly motile, grows very rapidly, is able to break down urea, and has Ags with cross reactivity with Rickettsia?

A. Proteus mirabilis

B. E. Coli

C. Klebsiella pneumoniae

D. Enterobacter

A

Proteus mirabilis

35
Q

Serratia is a member of the Enterobacteriaceae family and is most known for which of the following?

A. Rapid ability to grow and breakdown urea

B. Causing pneumoniae that produces a bloody sputum that resembles a red jelly

C. Highly motile and part of normal flora, whose strains often carry ampC

D. Production of very bright red pigment

A
  • A. Rapid ability to grow and breakdown urea (Proteus mirabilis)*
  • B. Causing pneumoniae that produces a bloody sputum that resembles a red jelly (Klebsiella pneumoniae)*
  • C. Highly motile and part of normal flora, whose strains often carry ampC (Enterobacter)*

D. Production of very bright red pigment

36
Q

T/F: Shigella is always a pathogen, and NEVER normal GI flora

T/F: Shigella has 4 species and they are all motile

A

True

False; non-motile

37
Q

Shigella is very similar to EIEC as they both invade intestinal epithelial cells and release Shiga toxin. However, what 3 things does Shigella not have that is used to help distinguish it from E. Coli?

A

No flagella

No lactose fermentation

No H2S

38
Q

T/F: Shiga toxin works by utilizing its B subunit to bind to the microvillus membrane in the colon, so that subunit A can enter the cell and inactivate ribosome 60S leading to the inhibition of protein synthesis and eventual death of the intestinal epithelial cells

A

True

39
Q

Between E. coli, Shigella, and Salmonella:

Which is motile, lactose fermenter, and produces H2S?

Which is motile, non-lactose fermenter, and produces H2S?

Which is non-motile, non0lactose fermenter, and does not produce H2S?

A

Which is motile, lactose fermenter, and produces H2S?

E. Coli

Which is motile, non-lactose fermenter, and produces H2S?

Salmonella

Which is non-motile, non0lactose fermenter, and does not produce H2S?

Shigella

40
Q

Vi antigen is a poly-saccharide antigen just like the K antigen that surrounds the O antigen in what member of enterobactericaea family?

A. E. coli

B. Shigella

C. Salmonella

D. Klebsiella pneumoniae

A

Salmonella

41
Q

A patient comes in complaining of fever, diarrhea, and abdominal pain. You notice rose colored spots on their lower abdomen and suspect Typhoid Fever. All of the follwoing is true of the pathogen that caused Typhoid fever Except?

A. The pathogen is likely salmonella choleraesuis

B. The pathogen is a Faculative Intracellular parasite

C. People can harbor the pathogen in their gallbladders and become chronic carriers

D. This pathogen takes a step beyond EIEC and Shigella and can invade lymph nodes

A

A. The pathogen is likely salmonella choleraesuis

NOTE:

The pathogen is likely Salmonella typhi

42
Q

Systemic dissemination that leads to sepsis is usually caused by Salmonella choleraesuis and not typhi. This sepsis usually affects all of the following locations, EXCEPT?

A. Bone

B. Brain

C. Lungs

D. GI tract

A

GI tract

NOTE:

People with sickel cell anemia are particularly at risk for developing Salmonella osteomyelitis

43
Q

What is the most common type of salmonella infection, out of the 4 diseases it leads to?

A. Typhoid fever

B. Carrier state

C. Sepsis

D. Diarrhea (Gastroenteritis)

A

Diarrhea (Gastroenteritis)

44
Q

All of the following is true of Yersinia Enterocolitica, EXCEPT?

A. Closely related to yersinia pestis which caused the bubonic plague through route of flea bite

B. Commonly aquired through fecal-oral route via animal products

C. Causes a RLQ pain that can be mistaken for appendicitis

D. Examination of the terminal ileum will reveal mucosal ulceration

E. All the above are correct

A

All the above are correct

45
Q

The activities of choleragen, the exotoxin used by Vibrio chlorea, causes rice water diarrhea be increasing which of the following activities?

A. Reabsorption of NaCl

B. Reabsorption of K and HCO3

C. intracellular cAMP

D. inactivation of G-protein

A

C. intracellular cAMP

NOTE:

Choleragen subunit B binds to the GM1 ganglioside on the intestinal epithelial cell surface and allows entry of subunit A. Subunit A binds and activates the G-protein, which promotes cAMP production intraceelularly. the intracellular cAMP promotes active and constant secretion of Chloride and Na, as well as blocks their reabsorption. Of course water follows the secreting salts, as well as potassium and HCO3.

46
Q

During summer break you decided to visit Japan. While their you got some sushi and after suffered a terrible bout of diarrhea. You most likely developed gastroenteritis from which of teh following enteric members of the Vibrioonaceae family?

A. Vibrio cholera

B. Vibrio parahaemolyticus

C. Campylobacter jejuni

D. Helicobacter pylori

A

Vibrio parahaemolyticus

NOTE:

Vibrio parahaemolyticus is the most common cause of diarrhea in Japan, and is a marine organism that you get from eating undercooked fish

47
Q

Rotovirus, E. Coli and _______ are the 3 most common causes of diarrhea in the world.

A. Vibrio cholera

B. Vibrio parahaemolyticus

C. Campylobacter jejuni

D. Helicobacter pylori

A

Campylobacter jejuni

48
Q

Which of the following correctly characterizes the symptoms associated with an infection of Campylobacter jejuni?

A. Absent fever with chronic abdominal cramps that preeceed dark stools

B. Abrupt and severe fever with nausea and vomiting

C. Fever followed by abdominal cramps half a day later, and then bloody loose diarrhea

D. Bloody loose diarrhea that is followed by compounding fever and headache with abdominal cramps

A

C. Fever followed by abdominal cramps half a day later, and then bloody loose diarrhea

49
Q

T/F: H. pylori is the most common cause of duodenal and stomach ulcers

A

False;

H. pylori is the most common cause of duodenal ulcerrs, BUT its the 2nd most common cause of stomach ulcers behind aspirin

50
Q

99% of the flora of our intestinal tract is made of obligate anaerobic gram-negative rods that comprise what family of enterics?

A. Enterobacteriodaceae

B. Vibrionaceae

C. Pseudobacteriodaceae

D. Bacteriodaceae

A

Bacteriodaceae

51
Q

This bacteriodaceae has low virulence but complicates surgeries or accidents that involve perforation of the bowels leading to abcesses developing. This bacteria is also known for being one of the few gram-negative bacteria that does not have an endotoxin.

A. Fusobacterium

B. Bacteroides fragilis

C. Bacteriodes melaninogenicus

A

Bacteroides fragilis

52
Q

This bacteriodaceae produces a black pigment when placed on blood agar, and can cause necrotizing anaerobic pneumoniae following GI aspirations during seizure or a druken state.

A. Fusobacterium

B. Bacteroides fragilis

C. Bacteriodes melaninogenicus

A

Bacteriodes melaninogenicus

53
Q

In regards to Pseudomonas Aeruginosa, what does Wind, Water, Wounds, and Wire refer to?

A

How debilitated individuals are affected, and the routes through which pseudomonas aeruginosa might enter to fsu

54
Q

Pseudomonas aeruginosa produces which of the following smells in the wounds of those infected or agar plates?

A. Oranges

B. Grapes

C. Chocolate

D. Burnt toast

A

Grapes

55
Q

Use the mnemonic BE PSEUDO to share the infections associated with pseudomonas aeruginosa.

A

Burns

Endocarditis

Pneumonia

Sepsis

External malignant otitis media

UTI

Diabetic Osteomyelitis

56
Q

One of the virulence factors of Haemophilus influenzae is the polysacharide capsule made of polyribitol ribose phosphate, in which there are 6 types (a-f). Which of the following types is the “bad” one as it implicated in the development of meningitis, epiglotitis and septic arthritis in children?

A. capsule A

B. Capsule B

C. Capsule C

D. Capsule D

E. Capsule E

F. Capsule F

A

Capsule B

57
Q

What are the 3 bacteria that are responsible for causing meningitis before 3 months of age?

What are the 2 bacteria that cause meningitis later in life (6 months-3 years)?

A

What are the 3 bacteria that are responsible for causing meningitis before 3 months of age?

Listeria, E. coli, Group B strep

LESs than 3 months

What are the 2 bacteria that cause meningitis later in life (6 months-3 years)?

Neisseria meningitides

Haemophilus influenze

did I get meningitis between the ages 6 months-3 years? NaH

58
Q

Haemophilus infleuenzae type B causes what 4 diseases?

A

before the vaccine H. influenzae caused MASS panic

Meningitis

Acute epiglotitis

Septic arthritis

Sepsis

59
Q

For which of the following disease is H. Influenzae the number cause of in infants?

A. Meningitis

B. Acute epiglotitis

C. Septic arthritis

D. Sepsis

A

Septic arthritis

60
Q

Haemophilus ducreyi is responsible for the STI chancroid. All of the following include descriptions of the STIs that should be included in the DDx of chancroid, however, which of them is the correct description of chancroid? Bonus: Name the other diseases based on the provided symptoms

A. Presence of painless, enlarged pus filled LN that appear after the primary ulcer/bilster disappears

B. Presence of a painless ulcer and swollen LNs that are bilateral and painless with no pus

C. Painful ulcer/blister and swollen painful pus filled LNs found unilaterally

D. Painful blisters/ulcers with systemic systems like myalgias and fevers

A
  • A. Presence of painless, enlarged pus filled LN that appear after the primary ulcer/bilster disappears- Lymphogranuloma venerum (LGV)*
  • B. Presence of a painless ulcer and swollen LNs that are bilateral and painless with no pus - syphilus*

C. Painful ulcer/blister and swollen painful pus filled LNs found unilaterally

D. Painful blisters/ulcers with systemic systems like myalgias and fevers- Herpes

61
Q

T/F: Chancroid caused by H. ducreyi is not usually accompanied with systemic symptoms

A

True

62
Q

Which of the following describe clue cells that help identify a Gardnerella vaginalis infection?

A. Vaginal discharge containing vaginal epithelial cells with tiny pleomorphic bacilli with cytoplasm

B. Vaginal discharge containing vaginal epithelial cells with tiny pleomorphic spiral cells with cytoplasm

C. Vaginal discharge containing vaginal epithelial cells with tiny pleomorphic cocci with cytoplasm

D. None of the above

A

A. Vaginal discharge containing vaginal epithelial cells with tiny pleomorphic bacilli with cytoplasm

63
Q

What does pertussis mean?

A. Violent stomping

B. Violent kicking

C. Violent cough

D. None of the above

A

Violent cough

Bordella pertussis is the causer of whooping cough

64
Q

Which of the following virulence factors of Bordetella pertussis is thought to be directly responsible for the production of the violent cough assoc. with infection and Whooping cough?

A. Pertussis toxin

B. Extracytoplasmic adenylate cyclase

C. Filamentous hemagglutin (FHA)

D. Tracheal cytotoxin

A
  • A. Pertussis toxin- increases cAMP*
  • B. Extracytoplasmic adenylate cyclase- increases cAMP*
  • C. Filamentous hemagglutin (FHA)- pili that allows attachment to epithelial cells*

D. Tracheal cytotoxin - destroys the ciliated cells

65
Q

All of the following are true of Yersinia, Francisella, Brucella, and Pasturella, EXCEPT?

A. All gram-positive

B. All zoonotic (primarily a disease of animals)

C. Very virulent and penetrate any body area they touch (usually the skin)

D. All faculative intracellular organisms except 1 of them

A

A. All gram-positive

They are all gram NEGATIVE

NOTE:

They are all faculative intracellular organisms except pasturella

66
Q

What does boubon mean and is thus a hint for the location of lymph nodes targeted by Yersinia pestis (causer of bubonic plague)?

A. Groin

B. Stomach

C. Breast

D. Head

A

Groin

67
Q

Francisella tularensis causes Tularemia and is most commonly acquired though contact with what?

A. Rats and fleas

B. Goats, cows, dogs, and pigs

C. Rabbits, ticks and deerlfy

D. Cat or dog bite

A

C. Rabbits, ticks and deerlfy

NOTE:

A- yersinia

B- brucella

D-pasteurella

68
Q

All of the following are faculative intracellular organisms EXCEPT which of the following? Hint: it is most commonly acquired through cat or dog bite.

A. Yersinia pestis

B. Fancisella tularensis

C. Brucella

D. Pasturella

A

D. Pasturella

69
Q

T/F: Chlamidiya and Ricketsia are gram-negative bacteria that are faculative intracellular parasites

A

False

Chlamidiya and Ricketsia are gram-negative bacteria that are obligate intracellular parasites

NOTE:

Both have to steal ATP energy from the host cell, which they are able to do due to them both having ADP/ATP translocator

70
Q

Unlike other gram negative bacteria, Chlamidiya is lacking which of the following?

A. Outer cell membrane

B. Peptidoglycan layer

C. Inner cell membrane

D. Literally nothing is different

A

Peptidoglycan layer

71
Q

Chlamidia trachomatis typically infects what 3 locations on the body?

A

Eyes

Genitals

Lungs

72
Q

Look at this

A

Noce

73
Q

Comparing Chlamidiya and Rickettsia:

______ is spread person-to-person, and ______ is spread through an arthropod vector.

______ replicates freely in the cytoplasm, and _______ replicates in endosomes.

________ likes columnar epithelium, and _______ has a tropism for endothelial cells that line blood vessels.

A

Chlamidia is spread person-to-person, andRickettsia is spread through an arthropod vector.

Rickettsia replicates freely in the cytoplasm, and Chlamidiya replicates in endosomes.

Chlamidia likes columnar epithelium, and Rickettsia has a tropism for endothelial cells that line blood vessels.

74
Q

Mycoplasm pneumoniae is the number one cause of self-limited bronchitis in which age group?

A. Neonates

B. Pediatrics

C. Young Adults and teens

D. Adults over 50

A

Young Adults and teens

MOD-Exam 3 (6 decks)

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