Exam II Review Flashcards

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1
Q

Describe innate and adaptive immunity in terms of their specificity

A

Innate is general, first and second lines of defense, recognizes things like peptidoglycan or flagella (general pathogenic characteristics)

Adaptive is specific, utilizes humoral (antibodies, B cells), and cell-mediated responses (T cells, helper and cytotoxic)

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2
Q

Skin is one of the first lines of defense for innate immunity, why can’t most pathogens penetrate the skin?

A

Dry, acidic, and salty

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3
Q

What do mucous membranes contain that works as the first line of defense for innate immunity, and how does it work?

A

Lysozyme: works by cleaving between NAG and NAM of peptidoglycan

Lactoferrin: iron scavenging (pathogens contain siderophores)

Lactoperoxidase and pH modification also possible

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4
Q

What is the second line of defense for the innate immune system?

A

Interferons [alpha, beta, and gamma]

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5
Q

Which interferon is responsible for enhanced phagocytic activity? (acts on bacteria)

A

IF-gamma

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6
Q

Which interferon is responsible for affecting neighboring cells and responds to viral infection?

A

IF-alpha and IF-beta

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7
Q

What are the innate immune defenses of the respiratory system?

A

mucous and ciliated cells in the nose and pharynx work to move things toward the throat to be coughed out

lower respiratory tract protected by alveolar macrophages and mucociliary escalator

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8
Q

What are the innate immune defenses of the eyes?

A

Lacrimal apparatus: produces tears containing lysozyme that can drain out the nose

also eyelashes, blinking

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9
Q

What is the function of eosinophils?

A

Protect us from large parasitic infections like helminths and roundworms using granzymes and perforin

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10
Q

What type of cells may act as phagocytic cells?

A

macrophages, dendritic cells, neutrophils

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11
Q

How do the chemical mediators of inflammation function?

A

prostaglandins release histamine and bradykinins which cause vasodilation and increased capillary permeability, resulting in edema/swelling

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12
Q

How does fever enhance our innate immune response?

A

By increasing metabolism and transferrins

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13
Q

Who secretes transferrins (host or pathogen) and what do they do?

A

Host secretes transferrins which prevents free iron from being taken up by pathogens with siderophores

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14
Q

When is fever detrimental? What cells are most sensitive?

A

If body temp goes too high; neurons/brain cells are the most sensitive to body temperature

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15
Q

What are the important chemical mediators of fever?

A

Activation of pituitary gland causing release of prostaglandins; interleukin-1 leads to T cell activation

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16
Q

Where do the 3 complement pathways converge?

A

C3

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17
Q

What are the 3 main activities of the complement?

A
  1. Formation of the membrane attack complex (MAC) which is dependent on C5 activation, leading to C6-9
  2. Opsonization - attraction of phagocytic cells
  3. Enhances inflammation
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18
Q

What are PAMPs and name examples

A

Pathogen Associated Molecular Patterns

LPS, Peptidoglycan, Flagella

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19
Q

What are TLRs and how do they work

A

Toll-like receptors; act as ligand-gated receptors that recognize PAMPs; can be located anywhere in/on the cell

*She gave the example of an inflammation response to TLR binding a PAMP

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20
Q

What is the difference between a TCR and a TLR?

A

TCR = T cell receptors; located on helper T cells and cytotoxic T cells ONLY

TLR = Toll-like receptor; found on all cells

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21
Q

Which will generate stronger response: T-independent B cell activation, or T-dependent B cell activation?

A

T-dependent B cell activation, which requires helper T cells. T helper cells require two signals in order to recognize a particular pathogen

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22
Q

Do helper T cells bind to free antigens?

A

NO

They only bind to antigens coupled with MHC class II molecule (on APC)

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23
Q

Where are MHC class I molecules found? What occurs if they are missing? What about when antigen is bound?

A

all nucleated cells; if they are missing, natural killer cells are activated. When antigen is bound they will activate cytotoxic T cells

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24
Q

True or false: there is only one pathway through which cytotoxic T cells can initiate cell death

A

False!

Cytotoxic T cells or Natural Killer cells can cause apoptosis, cell death, or necrosis

*Apoptosis is preferred response

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25
Q

What are the 3 types of APCs that exhibit MHC class II?

A

B cells, dendritic cells, and activated macrophages

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26
Q

What type of antigen is capable of linking MHC class II and T cells together, causing activation of T cell in the absence of a specific antigen?

A

Superantigen

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27
Q

There are 2 signals necessary to T cell activation, the first signal involves co-receptors. What are co-receptors?

A

CD4+ = helper T cells

CD8+ = cytotoxic T cells

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28
Q

Which type of T cell requires MHC class I presenting an antigen to the T cell receptor?

A

Cytotoxic T cell with co-receptor CD8+

this will lead to one of several pathways toward cell death

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29
Q

what type of cells produce antibodies?

A

plasma cells

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30
Q

What is the structure of an antibody?

A

Made up of light chains and heavy chains with two domains: variable region and constant region

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31
Q

Which region of an antibody binds to the antigen? Which region binds to the surface of the antibody?

A

Variable region binds to the antigen, constant region binds to the antibody itself

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32
Q

Where would you find an antibody such as IgM, IgG, IgA, IgD, or IgE?

A

In the blood!

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33
Q

Which antibody is the first to be produced in response to an infection? Second? What is the process called when the antibody present changes?

A

First is IgM - agglutination, Second is IgG

Class switching occurs between IgM and IgG

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34
Q

Describe the concept of combinatorial joining

A

Random deletion events in which variable exons are spliced together with constant region. The constant region dictates the class of antibody prior to forming final mRNA strand. Overall purpose is to create diversity of antibodies

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35
Q

What areas of the body should be free of microbes?

A

Lower respiratory tract, kidneys and beyond (bladder), blood, CSF

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36
Q

Where would you find the most normal flora?

A

intestines

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37
Q

What is a reservoir for Shigella?

A

water

*Reservoirs can be inanimate or animate!

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38
Q

Define vector

A

organism that spreads pathogen from one host to another; for example: arthropods (fleas, ticks, lice)

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39
Q

Fomite

A

inanimate object that can be contaminated with a pathogen

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40
Q

What are the stages of disease in order?

A

incubation period, prodromal stage, period of illness (may plateau or continue - chronic, convalescence

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41
Q

What is the portal of entry for an opportunistic pathogen invading a surgical site or abscess?

A

Parentaral route

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42
Q

Name 5 virulence factors that contribute to adherence

A

Fimbriae, pili, M proteins, capsules, and biofilms

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43
Q

Describe catalase

A

reactive oxygen species that are converted into water and gas; upregulation of catalase occurs in the phagolysosome

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44
Q

Describe coagulase

A

Converts fibrinogen into fibrin, forming wall around pathogen so phagocytic cells cannot get to it

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45
Q

What do proteases and kinases do?

A

proteases cleave immunoglobulins, kinases break down fibrin clots

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46
Q

Which pathogen is known to exhibit antigenic variation?

A

Neisseria with its varying pilum proteins

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47
Q

Which pathogens exhibit intracellular growth?

A

Chlamydia, Rickettsia, Shigella, Listeria

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48
Q

Which pathogen utilizes host cell actin?

A

Shigella

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49
Q

Name some exotoxins from organisms discussed in class

A

Botulinum toxin, Shigatoxin, Cholera toxin, Pertussis toxin, Superantigens, Enterotoxin

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50
Q

What does the pertussis toxin do?

A

causes mucous production, then cytotoxin kills ciliated cells which leads to paroxysmal cough

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51
Q

Lysogenic conversion occurs when phage infection brings in virulence factors. Name 2 organisms that exhibit lysogeny

A

S. pyogenes (strep throat) can lead to scarlet fever, rheumatic fever, cholera. Staphylococcal enterotoxin also.

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52
Q

What is the function of an Opa protein?

A

prevents T cell proliferation

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53
Q

Define bacteremia, toxemia, and viremia

A

Bacteria in the blood
Toxins in the blood
Viruses in the blood

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54
Q

What is the difference between infection and intoxication?

A

infection occurs when colonization by an organism results in disease

intoxication occurs due to the presence of a toxin (toxemia)

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55
Q

Compare botulism and tetanus toxins

A

Both have AB toxins, both are neurotoxins, both produced by clostridium species, both act on neuromuscular junction of synapses

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56
Q

Describe Botulism

A

flaccid paralysis due to blocked release of ACh

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57
Q

Describe Tetanus

A

rigid paralysis due to inhibited release of GABA and glycine

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58
Q

Toxins are named by activity. Describe an AB toxin

A

AB toxins have Active region and Binding region

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59
Q

What is an obligate intracellular parasite that has an RB and an EB?

A

Chlamydia

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60
Q

Why is Shigella unique for an enteric?

A

It lacks a flagellar antigen so it is non-motile; other enterics have flagella

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61
Q

What are K, H, and O antigens?

A

O is LPS on surface
H is flagella
K is capsule

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62
Q

What are 5 modes of transmission

A
airborne
contact
vehicle
vector-borne
vertical ---- example: Listeriosis!!
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63
Q

In what type of tests might fluorescence be used?

A

microscopy, cell sorting, flow cytometry

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64
Q

What is required for crossing the species barrier?

A

antigenic shift with recombination

65
Q

Naturally acquired active immunity

A

Type of specific immunity a host develops after exposure to a foreign substance (consequence of prior infection)

66
Q

Naturally acquired passive immunity

A

Transfer of antibodies, e.g., mother to fetus across placenta, or through breastfeeding

67
Q

Artificially acquired active immunity

A

Intentional exposure to a foreign material (vaccination)

Goal is to stimulate antibody production

68
Q

Artificially acquired passive immunity

A

Preformed antibodies or lymphocytes produced by one host are introduced into another host

Goal is to give antibodies directly

For example: immune globulin therapy

69
Q

What type of immunity is stimulated by vaccinations/immunizations?

A

Artificially acquired active immunity

70
Q

What type of organism is contained in an attenuated vaccine?

A

Live but avirulent (mutated)

71
Q

What type of organism is contained in an inactivated vaccine?

A

Dead

72
Q

What is a DNA vaccine?

A

DNA is directly introduced into host cell via gene gun, where DNA is taken into nucleus and pathogen’s DNA fragment is expressed so that host immune system can respond

73
Q

Describe acute, chronic, and latent disease

A

Acute: symptoms develop rapidly

Chronic: disease develops slowly

Latent: disease with a period of no symptoms when the causative agent is inactive

74
Q

Communicable disease

A

A disease that is spread from one host to another (a contagious disease is one that is EASILY spread)

75
Q

Noncommunicable disease

A

A disease that is not transmitted from one host to another (for example: botulism)

76
Q

What is a nosocomial infection and what is the most common type?

A

Hospital acquired infection often due to normal flora of patient or caregiver acting as opportunistic pathogens

Most common is urinary tract infection

Others include: surgical site infections, bloodstream infections (IVs), pneumonia (artificial airways)

77
Q

Endemic disease

A

Maintains a relatively steady low-level frequency at a moderately regular interval

78
Q

Hyperendemic disease

A

Gradual increase in occurrence frequency above endemic level but not to epidemic level

79
Q

Epidemic

A

Sudden increase in frequency above expected number

Index case is the first case in an epidemic

80
Q

Pandemic

A

Increase in disease occurrence within large population over wide region (usually worldwide)

81
Q

Name the 5 consequences of antibody binding of an antigen

A
Agglutination
Opsonization
Complement activation
Neutralization
Antibody-dependent cell-mediated cytotoxicity
82
Q

Define agglutination, one of the consequences of antibody binding of antigen

A

Agglutination reduces number of infectious units to be dealt with by sticking together

83
Q

Define opsonization, one of the consequences of antibody binding of antigen

A

Coating antigen with antibody, enhancing phagocytosis

84
Q

Define complement fixation, one of the consequences of antibody binding of antigen

A

Addition of complement causes inflammation and cell lysis

85
Q

Define antibody-dependent cell-mediated immunity, one of the consequences of antibody binding of antigen

A

Antibodies attached to target cell cause destruction by macrophages, eosinophils, and NK cells

86
Q

Define neutralization, one of the consequences of antibody binding of antigen

A

Blocks adhesion/attachment of bacteria, viruses, or toxins to mucosa

87
Q

When using hemagglutination testing, what is the positive result and why?

A

A positive result would be NO agglutination, meaning that the antibodies are present and preventing agglutination

88
Q

What is the indicator for complement fixation testing?

A

RBCs (hemolysis)

89
Q

Is complement fixation test direct or indirect?

A

Indirect, because looking for the presence of antibodies

90
Q

What is a positive result in the complement fixation test?

A

No hemolysis, because the complement is tied up in the antigen-antibody reaction

91
Q

What is the indicator for the ELISA test?

A

Peroxidase enzyme, reaction is visualized by addition of chromogen (color change)

(ELISA = Enzyme-Linked Immunosorbent Assay)

92
Q

What is adsorbed to the bottom of the well in the first step of a direct ELISA? What about an indirect ELISA?

A

Direct ELISA: antibody is adsorbed to the well, looking for antigen

Indirect ELISA: antigen is adsorbed to the well, looking for antibody

93
Q

What indicates a positive result during a neutralization test?

A

Indicator is cell damage; if antitoxins bind, they will be neutralized and we will see undamaged cells which is a positive result

94
Q

What would you assume had happened if a patient was not producing antibodies at one time, but two weeks later they were?

A

Seroconversion

95
Q

What type of serological test detects antigens from patient sample?

A

Direct

96
Q

What type of serological test detects antibodies in patient serum?

A

Indirect

97
Q

What method is used for identification of bacteria based on number of plasmids and their molecular weight?

A

plasmid fingerprinting

98
Q

What type of immunofluorescence involves unknown antigen added to antibody labeled with fluorescent dye resulting in visible fluorescence?

A

Direct, because the antibody is binding directly to the pathogen

99
Q

What type of immunofluorescence involves known antigen tested in different serums to see if there is fluorescence that occurs?

A

Indirect

100
Q

What type of antibody is produced by a hybridoma cell as an “immortal” cancerous B cell fused with an antibody-producing normal B cell?

Hint: these recognize a single epitope

A

Monoclonal antibodies

These are visualized with fluorescence

101
Q

Describe endotoxins in terms of their source, metabolic product, chemical make-up, ability to cause fever, ability to be neutralized by antitoxin, and magnitude of LD50

A
Source: gram-negative
Metabolic product: present in LPS of outer membrane 
Chemistry: lipid
Fever? YES (pyrogenic)
Neutralized by antitoxin? NO
LD50: relatively large
102
Q

Describe exotoxins in terms of their source, metabolic product, chemical make-up, ability to cause fever, ability to be neutralized by antitoxin, and magnitude of LD50

A

Source: mostly gram-positive
Metabolic product: by-products of growing cell
Chemistry: protein (soluble, heat-labile)
Fever? NO
Neutralized by antitoxin? YES
LD50: small (among the most lethal substances known)

103
Q

What does the hyaluronidase enzyme do in terms of resisting host defenses?

A

Hydrolyzes hyaluronic acid (found in connective tissue)

104
Q

What is the function of invasins?

A

Establish a niche, colonize an area, invade host cell defenses and prevent phagocytosis (innate), prevent antibody binding (acquired), and prevent attachment

105
Q

Members of normal microbiota that produce disease under certain circumstances, such as when they are misplaced to an area they are not normally found

A

Opportunistic pathogens

106
Q

What is a zoonose and give examples

A

Infections passed from animal to human

SARS (bats), tuberculosis (horses, cattle), typhus fever (rats)

107
Q

Define the symbiotic relationship: Commensalism and give an example

A

One organism benefits while the other is unaffected/unharmed

Example: Staph Aureus in your nose

108
Q

Define the symbiotic relationship: Mutualism and give and example

A

Both organisms benefit

Example: E. Coli in the gut benefit from rich nutrients, while they produce vitamins B and K for host benefit

109
Q

Define the symbiotic relationship: Parasitism and give an example

A

One organism benefits at the expense of the other (host is harmed)

Example: H1N1

110
Q
All of the following are involved in keeping the lower respiratory tract free of microorganisms except:
A. Ciliary escalator
B. Epiglottis
C. Alveolar macrophages
D. Lacrimal apparatus
A

D. Lacrimal apparatus

111
Q
Which of the following pathways for complement activation is generally dependent upon the formation of antigen-antibody complexes?
A. The classical pathway
B. The alternative pathway
C. The lectin pathway
D. All of the above
A

A. The classical pathway

112
Q
Which leukocytes function to produce toxins against certain parasites?
A. Lymphocytes
B. Basophils
C. Eosinophils
D. Neutrophils
A

C. Eosinophils

113
Q
Which host defense is more effective against gram positive bacteria than gram negative bacteria?
A. Mucus
B. Sebum
C. Gastric juice
D. Lysozyme
A

D. Lysozyme

Because of thicker layer of peptidoglycan, it will have a greater impact – gram negative are protected by outer membrane

114
Q

Natural killer cells specifically kill which of the following?
A. Gram positive
B. Gram negative
C. Fungi protozoa
D. Tumor cells and cells infected by microorganisms

A

D. Tumor cells and cells infected by microorganisms

115
Q
Each of the following is an effect of complement activation, except:
A. Opsonization
B. Increased phagocytic activity
C. Interference with viral replication
D. Increased blood vessel permeability
A

C. Interference with viral replication

116
Q
Eosinophils defend against protist and helminth parasites by:
A. Phagocytosis
B. Complement activation
C. Antibody production
D. Releasing perforin and lytic enzymes
A

D. Releasing perforin and lytic enzymes

117
Q

Which of the following is INCORRECTLY matched?
A. PAMP - peptidoglycan
B. TLR - stimulation of the inflammatory response
C. Histamine - vasodilation
D. None of the above

A

D. None of the above

118
Q

Class II major histocompatibility complex molecules are found on all of the following except:
A. B cells
B. T cells
C. Dendritic cells
D. None of the above, all have MHC class II molecules

A

B. T cells

119
Q

Which of the following releases histamine?

A. Mast cells
B. Basophils
C. Plasma cells
D. Mast cells and basophils

A

D. Mast cells and basophils

120
Q

Which of the following would you not find as normal flora in the nasopharynx?

A. Streptococcus pneumoniae
B. Escherichia coli
C. Neisseria meningitidis
D. Haemophilus influenza

A

B. Escherichia coli

121
Q

Which of the following areas of the human body is/are NOT normally free of microorganisms?

A. Upper respiratory tract
B. Intestinal tract
C. Eyes
D. All of the choices

A

D. All of the choices

122
Q

An inanimate object that may be contaminated with a pathogen is called a:

A. Vector
B. Fomite
C. Zoonose
D. Commensal

A

B. Fomite

123
Q

True or false: Generally, exotoxins tend to be more heat stable than endotoxins

A

False

Exotoxins tend to be more heat LABILE because they’re made up of protein

124
Q

Antibody molecules that are produced by a single hybridoma clone are called:

A. Human antibodies
B. Monoclonal antibodies
C. Hybrid cells
D. Identical antibodies

A

B. Monoclonal antibodies

125
Q

What is the most common type of nosocomial infection?

A. Lower respiratory infections
B. Postoperative infections
C. Bacteremia infections
D. Urinary tract infections

A

D. Urinary tract infections

126
Q

Which of the following measures is NOT used to prevent nosocomial infections?

A. Aseptic technique
B. Frequent handwashing
C. Increased use of antibiotics
D. Education of staff

A

C. Increased use of antibiotics

127
Q

What organism is the most important reservoir for the Borrelia burgdorferi?

A. Tick
B. Rabbit
C. Squirrel
D. Field mouse

A

D. Field mouse

128
Q

In what stage of syphilis do gummas develop?

A. Primary
B. Secondary
C. Tertiary
D. Latent

A

C. Tertiary

129
Q

Which urinary tract bacteria can cause headaches, fever, and possible kidney failure as a complication?

A. Escherichia coli
B. Staphylococcus saprophyticus
C. Leptospira interrogans
D. Neisseria gonorrhoeae

A

C. Leptospira interrogans

**E. Coli can cause UTIs but it is not a urinary tract bacteria

130
Q

True or False: M protein enhances the virulence of streptococcus by preventing phagocytosis

A

True

*M proteins function in attachment AND prevention of phagocytosis

131
Q

A nosocomial infection is:

A. Always caused by medical personnel
B. Always caused by pathogenic bacteria
C. Always present, but is not observed in times of hospitalization
D. Acquired during the course of hospitalization

A

D. Acquired during the course of hospitalization

132
Q

True or False: An endemic disease is constantly present in a population

A

True

133
Q

Which item is from the patient in a direct ELISA test?

A. Substrate for the enzyme
B. Antigen
C. Antihuman immune system
D. Antibodies against the antigen

A

B. Antigen

134
Q

Purified protein from Bordetella pertussis is used in a(n):

A. Attenuated whole-agent vaccine
B. Nucleic acid vaccine
C. Subunit vaccine
D. Toxoid vaccine

A

C. Subunit vaccine

135
Q

Bacillary dysentery is caused by:

A. Staphylococcus
B. Shigella
C. Salmonella
D. Clostridium

A

B. Shigella

136
Q

What is the main reservoir for Yersinia pestis?

A. Deer
B. Rodents
C. Small mammals
D. Rabbits

A

B. Rodents

137
Q

C. tetani causes the disease Tetanus by producing a(n):

A. Capsule
B. Endotoxin
C. Exotoxin
D. Enzyme

A

C. Exotoxin

138
Q

Which urinary tract bacterium can cause headaches, muscle aches, fever, and possible kidney failure as a complication?

A. Escherichia coli
B. Staphylococcus saprophyticus
C. Leptospira interrogans
D. Neisseria gonorrhoeae

A

C. Leptospira interrogans

139
Q

What is the etiological agent for the disease that has catarrhal, paroxysmal, and convalescence stages?

A. Borrelia
B. Streptococcus
C. Mycobacterium
D. Bordetella

A

D. Bordetella

140
Q

All gram negative bacteria contain:

A. Exotoxins
B. Endotoxins
C. Siderophores
D. IgA protease

A

B. Endotoxins

141
Q

C. Tetani causes the disease Tetanus by producing a(n)

A. Capsule
B. Endotoxin
C. Exotoxin
D. Enzyme

A

C. Exotoxin

142
Q

Septic shock can result from using antibiotics to treat

A. Fungal infections
B. Viral infections
C. Protozoan infections
D. Gram negative bacterial infections

A

D. Gram negative bacterial infections

143
Q

Arthropods provide a portal of exit for microbes in:

A. Skin
B. Blood
C. Respiratory tract
D. Genitourinary tract

A

B. Blood

144
Q

What is the clonal selection theory?

A

States that each lymphocyte has membrane-bound immunoglobulin receptors specific for particular antigen and after the receptor is engaged, proliferation of the cell occurs such that a clone of antibody producing cells is produced

145
Q

What is the clonal deletion theory?

A

The elimination of certain T cell populations in the thymus that have specificity for self-antigens (forbidden clones)

146
Q

Describe IgG in terms of its valence, where it is found, and function

A

Monomer - bivalent (2 binding sites)
Capable of complement fixation and crossing the placenta
Found in blood, lymph, and intestine
Enhances phagocytosis, neutralizes toxins and viruses, and protects fetus and newborn

**second antibody to appear in response to infection (M is first)

147
Q

Describe IgM in terms of its valence, where it is found, and function

A

Pentamer - (10 binding sites)
Capable of complement fixation
Found in blood, lymph, and on B cells
Agglutinates microbes, first antibody introduced in response to infection

148
Q

Describe IgA in terms of its valence, where it is found, and function

A

Dimer (4 binding sites)
Found in secretions
Functions in mucosal protection

149
Q

Describe IgD in terms of its valence, where it is found, and function

A

Monomer (2 binding sites)
Found in blood, lymph, and B cells
Functions in initiation of immune response on B cells

150
Q

Describe IgE in terms of where it is found and its function

A

Found on mast cells, on basophils (histamine), and in blood

Functions in allergic reactions; lysis of parasitic worms, opsonization

151
Q

During intracellular digestion, the phagosome fuses with lysosome to form ______, leading to degradation with hydrolytic enzymes and H2O2

A

Phagolysosome

152
Q

What are the cardinal signs of inflammation?

A
Redness
Warmth
Pain
Swelling/edema
Altered function
153
Q

Innate, nonspecific response to tissue injury caused by pathogen or physical trauma; it is the immediate response of the body to injury or cell death

A

inflammation

154
Q

What activates the classical pathway of complement system?

A

Antigen: antibody complexes (pathogen surfaces)

155
Q

What activates the Lectin pathway of complement system?

A

Mannose-binding lectin binds mannose on pathogen surface

156
Q

What activates the alternative pathway of complement system?

A

Pathogen surfaces - activation of C3 forms MAC

157
Q

What innate immune defense kills infected target cells by releasing granules that contain perforin and granzymes? In other words, helps protect cells that have not been able to produce “self” tag?

A

Natural Killer (NK) cells

Phagocytes then kill the infected microbes

158
Q

What are the innate functions of the gastrointestinal immune system?

A

Gastric acid in the stomach

Pancreatic enzymes, bile, GALT, normal microbiota, and peristalsis and shedding in the intestines