Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Medical microbiology > Subcutaneous mycoses > Flashcards

Subcutaneous mycoses Flashcards

You may prefer our related Brainscape-certified flashcards:
Biology 101 flashcards USMLE® Step 1 flashcards
1
Q

Other term for subcutaneous mycoses

A

inoculation mycoses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

causes of subcutaneous mycoses

A

traumatic impantation

inhalation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

etiological agents of subcutaneous mycoses

A

soil

decaying vegetable saprophytes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

T or F: subcutaneous mycoses are of high virulence

A

False, low virulence, seldom develops into life-threatening disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

characteristic of subcutaneous mycoses

A

nodular lesions which may suppurate and ulcerate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

T or F: secondary spread to articular surfaces, bone and muscle are common with subcut myco

A

true

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Biosafety level required for subcut myco

A

biosafety level 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

causative organism of sporotrichosis

A

Sporothrix schenkii

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

causative organisms for chromoblastomycosis

A

 Phialophora verrucosa
 Fonsecaea pedrosoi: most common
 Fonsecaea compacta
 Cladosporium carrionii

*dematiaceous fungi (contains melanin), slow-growing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

causative organisms for PHAEOHYPOMYCOSIS

A 
Cladosporium
Exophiala
Wangiella
Bipolaris
Exserohilum
Curvularia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

causative org for MYCOTIC MYCETOMA

A

Pseudallescheria
Madurella
Acremonium
Exophiala, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

co for SUBCUTANEOUS ZYGOMYCOSIS (Entomophthoromycosis)

A

Basidiobolus ranarum

Conidiobolus coronatus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

co for subcutaneous zygomycosis (MUCORMYCOSIS)

A 
Rhizopus
Mucor
Rhizomucor
Absidia
Saksenaea, etc.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

co for RHINOSPORIDIOSIS

A

Rhinosporidium seeberi

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

co for LOBOMYCOSIS

A

Loboa loboi

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

T or F: Fungal dimorphism is NOT exhibited by fungi that cause subcutaneous and systemic mycoses

A

false

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

conditions at which saprophytic and mycelia fungi survive

A

25C temp
humidity
nutrients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

conditions at which spherules and yeast (parasitic) survive

A

37C temp
hormone
tissues
immune response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Also known as “Rose gardener’s disease”, “Rose thorn

disease” or “Rose handler disease”

A

SPOROTRICHOSIS

*it is found in plants, soil, decaying vegetation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

T OR F: Sporothrix schenkii is an animal pathogen

A

false, human and animal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

T or F: Sporothrix schenkii is thermally dimorphic

A

True
*room temp: mycelia (saprophytic)-BRANCHING HYPHAE, white to dark brown
body temp: yeast (parasitic)- SPHERICAL TO OVOID BUDDING CELLS, cigar-shaped, cream to beige

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

colonies of S. schenkii on saboraud’s agar characteristics

A

cream to black color
folded
leathery colonies
grows within 3-5 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

modes of transmission for sporotrichosis

A

inhalation of conidia
cutaneous inoculation
zoonotic transmission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

most common type of sporotrichosis where lesions are usually localized at inoculation sites (fingers, hands, limbs)

A

fixed cutaneous s.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

what kind of lesions appear in fixed cutaneous sporotrichosis

A

Ulcerative, verrucose, acneform, papular, or erythematoid at face, neck or trunk

*Painless nodules to palpable and ulcerate lesions, may
discharge purulent or serous fluid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

sporotrichosis caused by traumatic inoculation of the fungus into the skin initially resulting to nodular lesion, which usually ulcerates

A

lymphocutaneous sporotrichosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

where do secondary lesions appear in lymphocut s.?

A

lymphangitic channels

*PATHOGNOMONIC OF LYMPHOCUT S.: SWELLING OF LYMPHATICS (nosystemic symptoms)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

t or f: Lymphocut s. is very painful and patients exhibit febrile stage

A

false: afebrile and minimal pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Pulmonary sporotrichosis is caused by

A

inhalation of conidia

  • fatal if untreated due to massive hemoptysis, non-specific symptoms
  • associated with COPD and ALCOHOLICS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

sporotrich. caused by direct inoculation of the fungus or hematogenous spread with cutaneous lesions present on limbs near affected joints (long bones)

A

Osteoarticular sporotrichosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

characteristics of osteoarticular sporotrichosis

A

stiffness and pain in joint
occurs more than 10 years
may lead to inflammatory monoarticular arthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

rarest sporotrichosis commonly occuring in immunocompromised and with alcohol abuse.

A

Disseminated sporotrichosis

*nodules: multiple, painless, cutaneous, subcutaneous

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

complications of disseminated sporotrichosis

A

Ulcers or abscesses in muscles, joints, eyes, bones, GIT, nervous system, and mucous membranes
Endophthalmitis (Aqueous or vitreous humor)
Chorioretinitis (Uvea/ middle layer of eye)
Meningitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

specimens needed for lab diag of sporotrichosis

A

pus or biopsy of lesions
sputum
CSF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

stain used in tissue biopsy diagnosis of sporotrich.

A

Periodic Acid Schiff (PAS) & Grocott’s or Gomori Methenamine Silver (GMS)

**low sensitivity due to low fungal count

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

S. schenkii is cultured in

A

SDA, BHI (with 5% sheep RBC), blood agar plate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

In culturing schenkii, what is used to confirm diagnosis?

A

yeast formation at 37C

*exception: fixed cut and lymphocut grow best at 35C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

appearance of KOH mount of s. schenkii colonies at 25C (septate hyphae)

A

Rosette-like clusters of conidia at the tips of the conidiophores
microconidia: daisy-like
Short conidiophores at RIGHT ANGLE from thin hyphae

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

appearance of KOH mount of s. schenkii colonies at 37C (yeast colonies)

A

Round/cigar-shaped yeast cells
Presence of asteroid bodies (Splendore-Hoeppli phenomenon) in histologic specimens
- Not pathognomonic!!, (also seen in parasitic infxn)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

serology tests for sera of sporotrich. patient

not diagnostic

A

 Yeast-cell (suspensions) agglutination test
 Antigen-coated latex particle agglutination test

*not sera: Sporotrichin skin test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

treatment for cutaneous-lymphatic form of sporotrichosis

A

oral potassium iodide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

treatment for systemic sporotrich.

A

amphotericin b (intravenous)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

drug of choice for sporotrich

A

itroconazole

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Also known as: chromomycosis, verrucous dermatitis,

cladosporiosis, phaeosporotrichosis, dermatitide verrucosa, chromoparasitaria, figueira, formiguero

A

chromoblastomycosis

*caused by black molds or copper- colored soil saprophytes found on rotting wood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

T or F: chromoblastomycosis is acute and fast-progressing

A

false, chronic and slow-progressing involving subcutaneous and cutaneous tissues

*considered as post-traumatic chronic infxn.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

progression of papules in chromoblastomycosis

A

papules develop into verruccoid, warty nodules resembling florets of cauliflower

*systemic infxn-rare

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

chromoblastomycosis is confined to

A

lower legs and feet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

causative organisms of chromoblastomycosis are similar in

A

appearance
antigenic determinants
physiological properties

*difference: shape of spores and arrangement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

development of papules for chromoblastomycosis

A

painless or itchy small scaly papules to small violet wart like lesion and clusters
*pathognomonic: CAULIFLOWER APPEARANCE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

how is chromoblastomycosis introduced to the body

A

puncture wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

T or F: chromoblastomycosis follows lymphangitic channels

A

true

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

prominent clinical manifestations of chromoblastomycosis

A

hyperplasia (tissue proliferation)
fibrosis and microabscess formationg in the epidermis

*common complication: secondary bacterial infxn

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

T or F: in chromoblastomycosis, there is formation of fistula and bones and muscles are invaded

A

False, exact opposite

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

causative organisms isolated from the brain

A

F. pedrosoi and P. verrucosa

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

specimens used for lab diagnosis of chromoblastomycosis

A

Crusts, skin scrapings, aspirated debris and biopsy, excised material

56
Q

pathognomonic of chromoblastomycosis seen in tissue biopsy

A

brown sclerotic fission cells resembling copper pennies

57
Q

reagents/stain used in direct microscopy of chromoblastomycosis

A

10% KOH
India ink or calcoflour white
tissues: H&E, PAS, GMS

58
Q

most reliable lab diagnosis of chromoblastomyc.

A

culture

59
Q

flask-shaped, flower in a vase appearance, conidia accumulate at end (chromoblasto)

A

phialophora

60
Q

characteristics of rhinocladiella (chromoblasto)

A
  • Acrotheca type of conidiation (Conidia at the ends and sides of conidiophore)
  • Simple conidiospores
  • May not differentiate from vegetative hyphae
61
Q

type of conidiation for cladosporium

A

hormodendrum (conidia = simple stalk)

*two or more conidia found at the tip which may bud and form secondary conidia until chains are formed

62
Q

Which causative org of chromoblasto can exhibit all three types of conidiation (hormodendrum, acrotheca, phialophora)

A

fonsecaea

63
Q

difference between f. pedrosi and f. compacta

A

compacta has more compact conidia and smaller conidia while pedrosoi is linked with acrotheca type of conidiation

64
Q

T or F: Serology tests are gold standard for diagnosing chromoblasto and phaeohypho

A

false, no available serological tests

65
Q

Treatment for chromoblastomyc

A

 Flucytosine with or without thiabendazole
 Itraconazole (400 mg/day) and Terbinafine (500 mg/day)

*surgery=impractical

66
Q

how do you differentiate phaeohyphomycosis from other fungal infections?

A

morphology of the organism while inside the host

67
Q

mycotic infections of humans and lower form of animals (common in cats, chicken, turkey and horses) caused by dematiaceous mycelial fungal organisms

A

Phaeohyphomycosis

68
Q

most common causative agents of phaeohyphomycosis

A

Phialophora

Cladophialophora

69
Q

other causative agents of phaeohy.

A 
Exophiala
Bipolaris
Phaeoannelomyces
Exerohilum
Aureobasidium
Wangiella
Alternaria
Curvularia
70
Q

modes of transmission of phaeohy.

A

traumatic inoculation from soil, plants, vegetation into the skin or subcutaneous tissue
inhalation ofconidia

71
Q

its common causative agents are exophiala jeanselmei and wangiella dermatitidis (traumatic inocu)

A

Subcut phaeohyp

*adults have cystic lesions
immunocompromised have verrucous lesions

72
Q

paranasal sinus phaeohyph sinusitis is caused by

A

exerohilum
alternaria
bipolaris
curvularia

*reported in immunocomp and with allergic rhinitis

73
Q

rare infxn caused by inhalation of conidia with cladiophialophora bantiana* as its common causative agent

*neurotropic fungi and moderately fast growin

A

cerebral phaeohyphomycosis

74
Q

specimens for lab diagnosis of phaeohyphomycosis

A

Biopsy, sputum or bronchial washing, skin scrapings, CSF, pleural fluid, and blood

75
Q

T or F: phaeohyphomycosis has same staining as chromoblasto

A

true

*significant finding: BROWN,BRANCHING SEPTATE HYPHAE

76
Q

Curvalaria characteristics

A

Fast-growing colonies
Suede-like to downy, brown to blacking brown with a black reverse
Pale brown conidia with ≥ 3 transverse septa that are formed at the apex of a pore (poroconidia)
Cylindrical conidia that are slightly curved
Bipolar germination

77
Q

Slow growing
Green, black colonies
Cultures with mycelial and yeast-like growth forms
Small oval conidia cluster on tip of conidiophore

A

Exophiala jeanselmei

78
Q

Wangiella dermatitidis characteristics

A

Slow-growing colonies
Initially yeast like and black then becomes suede-like, olivaceous-grey
Brown pigment is produced in agar

79
Q

Cladophialophora bantiana characteristics

A

Moderately fast growing
Olivaceous-grey, suede-like to floccose colonies
Conidia develop in long, sparsely branched, acropetal chains of undifferentiated

80
Q

treatment of choice for phaeohypho.

A

surgical excision

81
Q

Chronic, progressively destructive morbid inflammatory disease usually of the foot but any part of the body can beaffected also known as Madura Foot or Maduromycosis

A

Mycetoma

*see table in trans for causative agents

82
Q

nodules of mycetoma are described as

A

suppurative plaques affecting lower extremities

83
Q

signs and symptoms of madura foot

A 
 Old sinuses close while new ones open
 +/- pain
 Itching sensation/pruritus
 Regional lymphadenopathy
 Nodules, abscesses, and fistulae or draining sinuses
84
Q

three criteria that characterize mycetoma infection

A

 Draining sinuses
 Sulfur granules in tissue and in weeping drainage (Sclerotia or appearance of granules and grains)*
 Lesions that develop into swollen extremities (Tumefaction)

*active phase of disease

85
Q

what is the hallmark of mycetoma infxn

A

Sinuses discharge serosanguinous fluid containing granules

86
Q

granules of mcyetoma vary in

A

size
color
degree of hardness

87
Q

mycetoma commonly affects which part of the body

A

upper and lower limbs

88
Q

two types of mycetoma

A

actinomycotic

eumycotic

89
Q

actinomycotic mycetoma is caused by

A

microaerophilic and weakly acid fast higher form of bacteria:
actinomyces
nocardia (most common)

*invades muscles

90
Q

caused by black molds (true fungi) which invade subcut tissue

A

eumycotic mycetoma

91
Q

T or F: lesions in actinomycetoma are non-encapsulated, more inflammatory, destructive and invades the bone at an earlier period

A

true

92
Q

T or F: eymycotic mycetoma lesions grow more slowly, remain encapsulated for a long period, has clearly defined margins and late bone involvement (bone destruction;amputation is needed)

A

true

93
Q

Mycetoma should be differentially diagnosed from

A

Kaposi’s sarcoma, Fibroma, malignant melanoma, Fibrolipoma, and thorn granuloma

94
Q

Specimens used for lab diagnosis of mycetoma

A

Excised sinus or tissue biopsy
exudate
pus
serosanguinous fluid containing the granules (stained with parker ink/cw)

95
Q

in direct microscopy, the exudate, pus or tissue should be examined for

A

sclerotia

96
Q

culture of mycetoma is done in

A

BAP or SDA

97
Q

granules of actinomycetes

A

filaments with diameter of 0.5-1.0 μm, coccoid, and bacillary elements

98
Q

fungal hyphae of mycetoma

A

2-5 μm in diameter with any intercalary swollen cells

99
Q

T or F: fusarium solani are rapidly growing and become bluish brown when sporodochia are present (from whitish to cream)

A

T

100
Q

Madurella mycetomatis have slow-growing, flat and leathery colonies which turn from white to yellow to ___ to ____

A

yellowish brown to brown

101
Q

two types of conidiation of madurella mycetomatis

A

Flask-shaped philides with rounded conidia

Simple or branched conidiophores with pyriform conidia with truncated bases

102
Q

not very common causative organisms of mycetoma

A

Leptosphaeria

Pseudallescheria

103
Q

Recommended lab diagnosis for mycetoma

A

imaging (CT Scan, bone radiography, MRI, ultrasound)

104
Q

Rarely occurring infection caused by members of the phylum Zygomycetes (primitive, fast growing, saprophytic fungi) with cosmopolitan distribution

A

Zygomycosis

105
Q

causes subcutaneous and systemic zygomycosis (acute infxn associated with diabetes, starvation, extensive burns, IV drug abuse, steroid-induced hyperglycemia, and chemotherapies)

A

mucorales

*rainforests

106
Q

causes subcutaneous zygomycosis only

A

enthomophthorales

*horses

107
Q

Part of the body involved in zygomycosis

A

Rhino-facial-cranial area
Gastro-intestinal tract
Lungs
Skin

108
Q

type of mucormycosis which is a paranasal infxn following inhalation of fungal elements developed after germination of sporangiosphores in the nasal passage

A

Rhinocerebral

*major clinical form of mucormycosis

109
Q

T or F: Diabetes, hypergylycemia and renal transplant can put you in a higher risk of acquiring pulmonary zygomycosis

A

Tralse, rhinocerebral mucor mainly

diabetes and renal transplant-true

110
Q

caused by inhalation of sporangiospores into the bronchioles and alveoli leading to pulmonary infarction and necrosis with cavitation

A

Pulmonary mucormycosis

111
Q

Rare mucormycosis commonly associated with GI diseases and Severe malnutrition

A

Gastrointestinal mucormycosis

  • may cutaneous mucormycosis pa pero ez nalang yan
112
Q

Entomophthoromycosis/Rhinoentomophthoromycosis is characterized by

A

appearance of polyps or palpable masses
bilateral distortion of subcut tissue
Splendore-Hoeppli phenomenon (eosinophils located around the hyphae)
lack of vascular invasion

113
Q

causative agent of entomophthoromycosis which usually involves infections of lower extremities. Lesions appear as subcutaneous nodules followed by firm swelling attached to the skin (not muscle)

A

basidiobolus ranarum

114
Q

causative agent of entomophthoromycosis which involves the nasal mucosa and development of polyp in the upper respi passage

A

Conidiobolus sp.

115
Q

Specimens used for lab diagnosis of zygomycosis

A

 Skin scrapings (cutaneous lesions)
 Nasal discharges, scrapings and aspirates (rhinocerebral lesions)
 Sputum and needle biopsies (pulmonary lesions)
 Biopsy tissue from patients (GI/disseminated)

116
Q

in direct microscopy for zygomycosis what is examined

A

broad, infrequently septate, thin-walled hyphae, showing focal bulbous dilations and irregular branching

117
Q

describe colonies of ca of zygo in SDA

A

glabrous, radially folded with fine, powdery, white mycelium

118
Q

Chronic granulomatous infection of mucous membranes of nasopharynx, oropharynx, conjunctiva, rectum, and external genitalia

A

rhinosporidiosis

119
Q

usual clinical manifestation of rhinosporidiosis

A

vascular friable polyps on nasal mucosa or external eye structures (strawberry-like)

120
Q

etiological agent of rhinosporidiosis now classified as parasite (never been cultured)

A

Rhinosporodium seeberi

121
Q

Three stages of pathogenesis of rhinosporidium seeberi

A
  1. Local replication
  2. Hyperplastic growth of host tissue
  3. Localized immune response
122
Q

how does one usually acquire rhinosporidiosis

A

bathing or working in contaminated stagnant water

123
Q

most common site of rhinosporidiosis

A

nose> palpebral conjunctiva> genitalia and rectum

124
Q

seen in the nasal region of rhinosporidiosi infxn

A

 Local pruritus, coryza, sneezing, rhinorrhea postnasal
discharge
 Soft strawberry like polyps
 Epistaxis or unilateral nasal obstruction

125
Q

T or F: the eye region in rhinospori is symptomatic

A

false, although with redness, photophobia and tearing

126
Q

The skin region in rhinospori exhibits

A

papillomas that gradually become verrucous

127
Q

T or F: immunodeficiency is associated with the infection

A

false, it is not

128
Q

what is used as confirmatory diagnosis for r. seeberi if it cant be cultured?

A

spherules in biopsy specimen observed using PAS

*macerated tissue is also used

129
Q

“Lobo’s disease or lacasiozis” - Rare, chronic, localized, sub-epidermal infection

A

Lobomycosis

130
Q

characteristics of lobomycosis

A

 presence of keloidal, verrucoid, nodular lesions on the face, ears, or extremities (generally painless)
 Resembles leprosy or leishmaniasis and other subcutaneous mycoses like sporotrichosis and chromomycosis
Self-limited infection

131
Q

etiological agents of LOBOMYCOSIS

A

Loboa loboi
Paracoccidiodes loboi
Lacazia loboi

  • not yet cultured in vitro in artificial specimens
  • Slow-growing (kaya chronic) multiple budding yeast cells with a phagocytosis-resistant cell wall containing melanin
132
Q

confused with lobomycosis

A

Blastomyces dermatitidis or Paracoccidiodes brasiliensis

133
Q

who are affected with lobomycosis

A

humans and family Delphinidae (whales + dolphins)

* no human to human transmission

134
Q

lesions of lobomycosis

A

regress and form a scar (keloids)

135
Q

what is examined for in tissue specimens for lobomycosis

A

long chains of darkly pigmented, spherical cells interconnected by tubules (yeast-like cells with a diameter of 5-12 μm)

136
Q

stains used to distinguish yeast cells

A

PAS, GMS or Gram

137
Q

stain used for atrophic dermis with fibrous, diffuse, inflammatory granuloma containing histiocytes and giant cells

A

H&E stain

Medical microbiology (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions