UWorld Block 2 Flashcards
Clonidine mechanism
å-2 adrenoreceptor in brainstem resulting in reduced sympathetic. outflow from CNS leading to decrease in peripheral vascular resistance, heart rate and BP.
Eastern USA and central america mycosis
Blastomyces
Filtered load ,excretion rate , reabsorption rate, secretion rate
Filtered load : GFR X [plasma]
Excretion rate: V X [urine]
Reabsorption rate= filtered load- excretion rate
Secretion rate: excretion rate- filtered load.
Postoperative urinary retention
Anasthesia and analgesia contribute to :
-over distention of bladder, decreased micturition reflex
-decreased contractility of detrusor muscle and incomplete empyting.
Contraction of detrusor is stimulated by muscharinic cholinergic agonist (eg bethanecol)
Large friable vagitations on valve cusps along with destruction of valve leaflets
Mitral stenosis due to infective endocarditis.
Acyclovir mechanism of action
In infected host cells, acyclovir (a neucleoside analogue) is converted into acyclovir monophosphate —> acyclovir triphosphate –> competes with deoxygunanosine triphosphate for DNA polymerase.—> acyclovir triphosphate incoporated into replicating viral DNA—> DNA synthesis stops.
Hepatitis B serological markers
- HBsAG: detectable during acute infection, persistence implies chronic infection.
- Anti-HBs: appearance indicates resolution of acute infectionor vaccination. (Long term immunity)
- Anti HBc IgM: present during windows phase when both HBsAg and anti-HBs are absent,
- Anti HBc IgG: not present after vaccination. Present in both acute and chronic.
- HBeAg: marker of high viral replication in chronic infection
- Anti-HBe: presence in chronic infection indicates low viral replication and infectivity.
Phenylpherine effect on bladder
It encourages the trigone and sphincter to contract. –> urinary retention .
Endocarditis with intact valve, etiology
S.aureus
Doest vasectomy affect the volume of ejaculation
Semen is composed primarily of fluid secreted from the seminal vesicles and prostate, spermatozoa consists onlt of 2-5% of semen by volume.
Fungal cell wall- target for which antifungal
Major polysacharide component of fungal cell wall is 1,3 beta D glucan.
Caspofungin and other “fungin” anti fungals blocks glucan synthesis.
They are especially effective against candida and aspergillus.
What is the most common cause of mitral stenosis
Rheumatic fever
Celiac disease presentation
Diarrhea, weight loss , and abdominal pain. Some patients presents with constipation.
Paraclinical : elevated serum transglutaminase
Microglia in post-stroke
As neurons disintegrate their fragments begin to be phagocytosed by microglia. The abundance of lipids seen in the cytoplams of the microglia results from extensive phagocytosis of myelin breakdown products.
Ependymal cells are
Cilliated glial cells that lines the ventricles of the brain and the central canal of the spinal cord.
Urge incontinence drugs
Anticholinergic such as oxybutyinin
Case: Paroxysmal hypertension, flushing, diaphoresis, and episodic headache
Pheochromocytoma
Coccidiosis immitis :clinical
- pulmonary form : flu-like illness, cough ,erythema nodosum.
- disseminated: affects skin, bones, and lungs.
Subflacine herniation
Cingulate gyrus herniates under the falx cerebri, potentially compressing the ACA.
Galactosemia: enzyme affected
Glactose 1 phosphate uridyl transferase defeciancy (galt)
Normal :galactose –> galactose 1 phosphate –> glucose 1 phosphate .
Galactosemia: galactose 1 phoshpate __X__ —> glucose 1 phosphate.
This means accumulation of galactose 1 phosphate.
Cat scratch disease
Bartonella henselae (bacillary angiomatosis) (pic)
In case of portal hypertension signs with normal liver in biopsy the most likely cause would be
Portal vein thrombosis
Reduced ß-globin synthesis results in
- microcytic microchromic anemia
- precipitation of unpaired å chain within red cell precursors in the bone marrow (ineffective erythropoiesis) and lysis of circulating erythrocytes (extravascular hemolysis)
Blastomyces
Culture 25˙ : branching hyphae,
biopsy: large round yeast with doubly refractile wall and single broad based bud.
FISH
Fluorescence in situ allows direct visualization of genes to their respective chromosomes by using labeled DNA probe complementary to the sequence of interest.
Paracoccidioides brasiliensis
Culture 25C˙ : multiple blastoconidia
Biopsy: cells covered in budding blasoconidia.
Lateral nucleus of hypothalamus
Mediate hunger,injury –> increased satiety.
ß-blockers intoxication, signs and symptoms
Bradycardia , hypotension and hypoglycemia.
Glucagon is the antidote
Repair mechanism in CNS after injury(stroke)
Repair is performed by astrocytes the migrate to the are within 2 weeks of injury (timeline is important). As necrotic tissue is resorbed a cystic space forms that is then surrounded by astrocytes and newly formed capillaries.
MAC complex deficiency– predisposition to ?
- neiseseria species.
- clinically patients experiences recurrent infections by neisseria.
Vasectomy: procedure and consequences
- resection of vas deferens( its function isnt only transporting sperm rather store and protect it)
- vasectomy blocks the transport of new spem from the epididymis, but has no effect on sperm distal to the ligation.
- patients can still have viable sperm in the distal vas for 3 months and at least 20 ejaculations after vasectomy.
- sexual intercourse may be resumed within 1 week , however pregnancy will still be probable. Another method of contraception should be done untill azospermia is confirmed.
Isoproterenol, mechanism of action
Non selective ß adrenergic agonist.
- It increases cardiac contractility by acting on ß1
- decrease systemic resistance by acting on ß2
- negligible effect on å-adrenergic receptor.
Decrease in both extra and intra-cellular potassium is seen in
- Mineralocortiocoids excess
- Diuretics
- Chronic GI loss
Prolonged isoniazid treatment can lead to
B6 vitamin deficiency. This may lead to siderblastic anemia.
Isoniazid inhibits the enzyme pyridoxine phosphokinase which in turn activates vitamin B6. Activated B6 is a cofactor for ∂-aminolevulinic acid synthase (ALA).
What is the normal post void residual urine volume
Less than 50 cc
Gliosis (glial scar formation)
The enlargement and proliferation of astrocytes peripherally around the are of necrosis after injury (e.g stroke)
Why is stress incontinence more common in women
- Because injury to EUS or pudendal nerve is common during vaginal child birth.
- In post menopause: decreased estrogen –> weak pelvic floor support.
Lyme disease: stages
Stage 1- early localized erythema migrans, flu-like symptoms
Stage 2- early disseminated secondary lesions, carditis, AV block, facial nerve palsy, migratory myalgia/transient arthritis.
Stage 3- late disseminated, encephalopathies, chronic arthritis.
Histoplasma diagnosis
Culture: 25C˙ : branching hyphae
Biopsy : oval yeast cells within macrophages.
Iron poisoning clinically
Hematemesis and melena( iron is toxic to gastric mucosal cells)
Multiple sclerosis is
Autoimmune demylinating disorder the typically affects young women with neurological deficits( eg, blurry vision ,diplopia ,focal weakness and numbness, dysarthria, bowel/bladder dysfunction).
- common initial manifestation is optic neuritis, characterized by monocular visual loss with pain on eye movement and an afferent pupillary defect.
- MS involves autoimmune response targeting oligodendrocytes, the mylin producing cells of the CNS.
Fibrillin -1 gene mutation leads
Autosomal dominant marfan syndrome
Azoles (itraconazole etc.. ) mechanism of action
Inhibit synthesis of ergosterol
Histoplasma capsulatum
Dimorphic fungus that is found as mold in soil.
Mississippi and ohio river basins.
In Lungs. Fungus is ingested by macrophages and seen on light microscopy as small intracellular oval bodies.
Opoid intoxication signs
- Severe sedation
- Respiratory depression
3.constricted pupils.
Naloxone antidote
Stress incontinence is due to
Urethral sphincter dysfunction.
- The internal urethral sphincter is mainly smooth muscles controlled by the autonomic nervous system. (Sympathetic -contraction, parasymphatetic- relaxation).
- the external urethral sphincter (EUS) is mostly pelvic floor skeletal muscles under voluntary control.
- after bladder is full, parasympthateic system contracts detrusor muscle and relaxes internal sphincter, but EUS prevents leaking of urine, in case of problems in EUS, stress inconteinence results .
Sporthrix schenckii
Associated with gardening , clinically : pustules ulcers and subcutaneous nodules along lympahtics
Theophylline side effects
In low to moderate cases: cortical arousal and insmonia
Acute: nausea, vomiting , abdominal pain, diarrhea, cardiac arrhythmia, and seziures.
Kozak consensus sequence
Is analogue to shine-dalgarno sequence in E.coli. Its defined by the following sequence: (gcc)gccRccAUGG, in which R is either adenine (A) or (G)guanine.
If R isn’t A or G but instead C this can impair the initiation of translation. (Check image)
Lead poisoning complication in children
Neurologic , GI, renal and hematologic
- Neurologic : loss of milestone/ cognitive impairment, behavioral problems and encephalopathy
- GI: constipation , abdominal pain and decreased vitamin D reabsorption.
- Renal: interstitial nephritis
- Hematologic: Anemia, sideroblastic
Microscopical sequence of stroke
First 48 hrs
3-5 days
Week
- First 48 hrs after injury –> irreversible damage (red neurons)
- neutrophils initially move into ischemic area followed by microglia (important) 3-5 days after the onset of ischemia.
MEN IIB result from mutation in
Germilne mutation in RET proto-oncogene.
Co-transational protein targeting is mediated by
N-terminal amino acid sequence of an elongating polypeptide. The signal sequence is recognized by a signal recognition particle which helps transport the protein to the RER
Portal vein thrombosis
Portal hypertension, splenomegaly , and varicosities at portocaval anastamoses. However it doesnt cause histologic changes to hepatic parynchema.
Ascitis is uncommon as the obstruction is presinusoidal
Billiary atresia
Pathogenesis and clinical:
Complete, or partial obstruction of extrahepatic bile ducts.
Biliary tree is normal at birth and subsequently undergoes destruction through immune or viral response.
Clinical:
Healthy infant, with Jaundice after 2 months of life.
Dark urine and pale or clay colored stools.
Taznck smear
HSV
What are protoglycans
They are composed of glycosaminoglycans which provides compressibility to tissues. Patients with deficiences in lysosomal enzymes cant break down GAGs, resulting in mucopolysaccharidoses such as hunter and hurler syndromes charactrized by soft tissue and skeletal disease.
Neural crest cells give rise to
-autonomic, sensory and celiac ganglia,
-schwann cells
-pia and arachinoid
-aorticopulmonary septum and endocardial cushions
- adrenal medulla
-
Arnold chiari syndrome - type I
Type I more common and benign, is characterized by low lying cerebral tonsils that extends below the foramen magnum into vertebral canal. Patients typically presents during adolescence/adulthood with paroxysmal occipital headache and cerebral dysfunction due to compression on cerebellar tonsils.
Iodothyronine deiodinase
Removal of iodine from T4 to make T3 in the periphery
Ehlers danlos syndrome clinical features and pathophysiology
Is a group of heridetery disorder involving a defect in collagen synthesis. EDS usually manifest as hyper-mobile joints, over elastic skin and fragile tissue susceptible to bruising, wound and hemarthrosis.
-common mutation leading to EDS phenotypes include deficiencies of the lysyl hydroxylase and procollagen peptidase enzymes responsible for collagen synthesis.
Thiazide diuretics effects on Ca+2
It increases Ca+2 reabsorption in the distal tubule. Thats the reason its indicated for hypertensive patients with risk of osteoporosis. This also can prevent Ca+2 stones.
Sporothrix schenckii : culture and biopsy
Culture: 25C˙: branching hyphae
Biopsy: round or cigar shaped budding yeast.
Bladder and urethra embryonic derivative
Endoderm
Where is lead found
Current lead exposure occurs through contact with dust/pain in homes built before 1978.
Breast milk jaundice
- Peaks at age of 2 weeks
- enzyme involved, beta glucuronidase.
Myelin producing cells
- Oligodendrocytes: affected in MS, CNS
2. Schwann cells: affected in peripheral demylinating disorder( gullain barre syndrome), PNS
DKA effect on K+
Increases extracellular potassium and decrease intracellular potassium.
This is due to :
1. Loss of intracellular free water caused by increased plasma osmolarity leads to extracellular movement of potassium secondary to increasing intracellular potassium concentration.
2. Lack on insulin.
CML characterstics
Characterized by uncontrolled proliferation of myeloid stem cell due to chromosomal translocation. This causes BCR and ABL to fuse together forming BCR-ABL fusion gene.
RT-PCR can be used to identify mRNA transcribed from the BCR-ABL fusion gene and this diagnose CML.
HIrschprung disease : clinical
- Billous vomiting,
- abdominal distention,
- failure to pass meconium
- failure of internal anal sphincter relaxation
- toxic megacolon
Intraerythrocytic ring inclusions
Malaria and babesia
ALA synthase and ALA dehydratase deficiency
ALA synthase deficiency is present in B6 deficiency (eg. isoniazid treatment)
ALA dehydratase deficiency is present in lead poisoning
Green color of pus and sputum in pneumonia
Its present in pneumococcal pneumonia.
Neutrophil myloperoxidase is responsible for the green color of pus and sputum in bacterial infections. Its a blue-green heme based pigmented molecule contained within the auzurophillic granules of neutrophils and catalyzes the production of hypochlorus acid from chloride and hydrogen peroxide during respiratory burst
AntiFungal targeting fungal Cell membrane
Amphotericin-B( binds ergosterol)
Leads to pore formation
Transtentorial herniation occurs when the ((long))
medial temporal lobe (uncus) herniate through the gap between the crus cerebri and the tentorium.
The most common cause of transtentorial herniation is an ipsilateral mass lesion (tumor, hematoma,hemorrhage..). This mass cause increase in supratentorial pressure on the side of the lesion and forces parahippocampal uncus through tentorial incisure.
As a result following become compressed :
1. Ipsilateral oculomotor nerve (CNIII) leads to fixed and dilated pupil on side of compression.
2. Ipsilateral posterior cerberal artery: homonymus hemanopsia with macular sparing
3. Cereberal peduncle (contralateral) -> ipsilateral hemiparesis.
4. Brainstem hemorrhages: duret hemorrhages may occur in pons and midbrain (fatal)
Deficient intracellular killing– what syndrome?
Chronic granulomatous disease (CGD).
Patients suffers from recurrent infection with catalase positive organisms such as staphylococci
Babesiosis epidemiology
Its common in northeastern USA,( massachusetts), outdoor exposure in the summer.
Erythema migrans
Seen in lyme disease.
It begins as erythmatous macule 7-14 days following the tick bite and enlarges with an advancing erythmatous border as the bacteria migrate slowly through skin from inoculation site.
The classic lesion is erythmatous and ring shaped with central clearing. Typically described as bulls eye rash, although might be uniformly red.
Reverse trascription PCR used to detect
Its used to quantify levels of mRNA in a sample.
It’s similar to regular PCR in that it uses sequence specific primers, thrombostable DNA polymerase and a pool of deoxyriboneucleoside triphosphates to amplify DNA template.
What are the drugs of choice in theophylline intoxication
- Beta blockers for theophylline induced cardiac tachyarrythmias.
- Theophylline induced seziures are difficult to treat but benzodiazepines and barbiturates are most effective.
- activated charcoal to reduce GI absorption.
Ct-> during first week after acute stroke
Reveals the ischemic area to be hypo-dense and poorly delineated from the surrounding tissue. Edema and loss of distinction of the gray white matter junction also seen
Aedes vector for
- dengue fever
- chickungunya
- both common in Florida. Appear with arthlagia and rash
Subendothilial collagen and glycosaminoglycans role
They form the subendothilial cap over the central core of an atherosclerotic plaque and are potent platelet activators. They contribute to rapid thrombus formation that can lead to myocardial infarction in coronary artery.
Thyroid peroxidase is
Multifunctional enzyme responsible for :
- catalyzing the oxidation of iodide
- the iodination of thyroglobulin
- coupling reaction between 2 iodized tyrosine residues.
Mitral regurgitation following dental procedure in MVP patients
Etiology most likely to be: viridans streptococci, this may cause transient bacteremia after dental procedure. These gram positive organisms are capable of producing extracellular polysaccharides (dextrans) using sucrose as a substrate.
Coccidioides immitis : diagnosis:
Culture (25c˙) forms hyphae, biopsy 37C˙, forms thick walled spherules filled with endospores.
Terbinafine mechianism and indication
Inhibits fungal enzyme squalene epoxidase
Used in dermatophytes
Neprilysin inhibitors
Neprilysin inhibitors or neutral endopeptidase inhibitors are used in heart failure.
E,g: sacubitril, valsartan
Reabsorption of water in the kidney
- proximal tubule reabsorbs >60% of the water filtered by the glomeruli regardless of hydration status.
- loop of henle , approximately 20%
- collecting duct approximately 20% , allowing for 99% of the water to be reabsorbed in dehydration state.
What is anisopoikilocytosis
Variation in size and shape.
Polypeptide elongation
The ribosome moves 3 nucleotides towards the 3’ end of mRNA, advancing peptidyl tRNA from the A site to the P site( translocation). Translocation is catalyzed by elongation factor 2 and requires GTP.
- Diagnosis of lead poisoning
2. What enzymes does it inhibit
- Measuring blood lead level, also urine ∂-aminolevulinic acid (heme synthesis substrate ) is elevated.
- Inhibits ALA dehydrogenase and Ferrochelatase.
Urge incontinence is due to
Detrusor overactivity that causes a sudden and frequent urge to urinate and empty the bladder. Triggers can include running water, hand washing or exposure to cold whether.
- loss of inhibitory central nervous system input to the bladder due to frontal love and internal capsule infarcts commonly causes detrusor hyperreflexia and urge incontinence.
Does neutrophils stain for lipids in brain biopsy
No,neutrophils dont phagocytose mylin remnants and therefore doesn’t. Microglia on the other hand does.
Dextran role in viridian’s streptococci
It facilitates streptococcal adherence to fibrin. Fibrin and platelets are deposited at sites of endothelial trauma providing a site for bacterial adherence and colonization during bacteremia. In patients with preexisting valvular lesions, viridian’s streptococci can adhere to affected valve and lead to endocarditis.
Latin america fungi
Paracoccidiodomycosis
Dystrophic calcifications
Its considered the hallmark of cell injury and death occurring in all types of necrosis (coagulative, fat ,caseous, liquefactive) . In the setting of normal Ca+2 levels. Grossly, dystrophic Ca+2 deposits are seen as fine gritty, white granules or clumps.
-this is common in aortic valve is it may lead to aortic sclerosis in benign cases and more severely may lead to calcific aortic stenosis
Mycosis in Mississippi and Ohio
Histoplasmosis
Tonsillar herniation
The cerebellar tonsils displace through the foramen magnum and compress the medulla.
Southwestern USA, california, mycosis
Coccidiosis immitis
How is hirchprung diagnosed
- Anorectal manometry: measures rectal pressure via rectal catheter and shows absent relaxation of internal anal sphincter.
- biopsy for confirmation. And definitive diagnosis.
Atrial naturitic peptide-> effects
Its secreted by the atrial cardio-myocytes in response to atrial stretch.
ANP binds to naturitic peptide receptor on cell membranes forming cGMP.
1. In kidney: dilate afferent arterioles, increase GFR and urinary excretion of Na and H2O.in addition it inhibits renin secretion.
2. Adrenal gland: restricts aldosterone secretion, leading to increase in sodium and water excretion by kidneys
3. Blood vessels: relaxes vascular smooth muscles in venules and arterioles , it also increases capillary permeability, leading to fluid extravasation into the interstitium and decrease in circulating blood volumes
Dimorphic fungi
Means these fungi forms molds with hyphae in ambient tempretures (25-30C˙) and yeast (single cell) at body tempreture (37C˙). Types include (5) 1. Sporothrix schenckii 2. Blastomyces 3. Histoplasma 4.coccidioides immitis 5. Paracoccidioides brasiliensis
Metastatic hypercalcemia
Its typically occur in alkaline tissues involved in acid secretion such as GI mucosa, kidney, lungs and systemic arteries.
Pneumococcal Pneumonia presentation in non-elderly
Abrupt onset fever, rigors ,tachypnea, and productive cough with consolidation on one lobe of the lung. Tobacco use increases its risk.
Acetaminophen toxicity treatment
Actylcysteine
Why amiodarone can affect thyroid
Because its 40% iodine by weight.
Kerniecterus
Bilirubin deposition in brain
Babesiosis: clinical, and diagnosis.
- Agent is babesia microti, vector is ixodes tick
- Clinically present with fever, fatigue, mylagia, headache, flulike symptoms( if severe ARDS,CHF,DIC and splenic rupture).
- Lab: anemia, thrombocytopenia and LFT elevated.
- diagnosis: thin blood smear (wright/giemsa stains): intraerythrocytic plemorphic ring forms (maltese crosses)
Furosemide effect on Ca+2
It increase it loses. –> hypercalciuria
Thiazide diuretics mechanism
It inhibits the Na-Cl cotransporter in the distal convulated tubule, leading to decreased sodium reabsorption. They also cause peripheral vasodilation leading to decreased vascular resistance.
Antifungal that inhibits the synthesis of both DNA (replication) RNA (protein synthesis)
Flucytosine
Used in treatment of cryptococcal meningitis
Intracellular hemosiderin accumulation
Common in hemolytic anemia patients or patients who undergo frequent blood transfusions.
GFR and filtration fraction
GFR = [U]inulin X V // [P]inulin
Filtration fraction = GFR/RPF
Bladder emptying is mainly done by
Detrusor muscle contraction
Mesoderm derivatives (unique)
- cardiovascular system
- spleen
- internal genetalia
- kidney and ureters
- adrenal cortex
Arnold chiari syndrome type II
More sever and typically becomes evident during neonatal period. Its characterized by downward displacement of the cerebellum( vermis, tonsils ) and medulla through the foramen magnum. Patients may have an associated meylomeningocele .
Overflow incontinence due to
Due to impaired detrusor contractility (e.g diabetic autonomic neuropathy) or bladder outlet obstruction (e.g tumor obstructing urethra) causing incomplete bladder evacuation.
Dog contact : infections
- rickettsia rickettsii
- pasturella multocida
- Capnocytophaga species
Green sputum
Due to myeloperoxidase, blue green heme based enzyme that is released from neutrophil azurophillic granules.
Histoplasma capsulatum:
Pulmonary similar to TB(granulomas with calcification)
Disseminated: Lung, spleen and liver
Types of incontinence
- Stress: due to decreased sphincter tone and urethral hyper-mobility.(most common cause)
- Urge: detrusor hyperactivity
- Overflow: impaired detrusor contractility.
Ventromedial nucleus in hypothalamus
Mediate satiety, injury–> hunger
Difference between crigler najjar and gilbert syndrome.
Gilbert syndrome have reduced glucuronyl transferase while crigler najjar have absent enzyme.
Crigler najjar have 2 types, type II is milder.
N.meningitidis clinical presentation
High fever, chills , altered mentation , petechial skin rash from neisseria induced small vessel vasculitis (affecting palms and soles) and ultimately septic shock.
Tx: ceftriaxone for 2 weeks.
Where does termination of polypeptide synthesis occur
At stop codons.
UGA
UAA
UAG
Diffuse fibrous thickening and distortion of the mitral valve leaflets, commissural fusion at the leaflet edges and narrowing of mitral valve orifice
MS due to ARF
Gilbert syndrome
Inherited benign condition of reduced production of glucuronyl transferase. Which is responsible for glucuronidation.
Patients usually asymptomatic except at times of stress.
Amiodarone side effects: cardiac ,pulmonary ,endocrine, GI, hepatic, ocular, dermatologic, neurological.
- Cardiac : sinus bradycardia,heart block and proarrythmia(QT prolongation).
- Pulmonary: chronic interstitila pneumonitis.
- Hypo or hyperthyroidism.
- GI and hepatic: elevated transaminases, hepatitis.
- Ocular: corneal microdeposits and optic neuropathy.
- Dermatologic : blue-gray skin discoloration
- Neurologic: Peripheral neuropathy
8 reproductive: it can cause erectile dysfunction by å and ß blockade effects
Eukaryotic translation initiation requires
Assembly of ribosomal subuints (60S and 40S), mRNA, initiaion factor, initiator tRNA charged with methionine and GTP.
Renal plasma flow
And renal blood flow
Its the clearance of PAH
RPF=C{PAH} = [U]PAH X V // [P]PAH
RBF= RPF/1-hematocrit
High bacterial load pneumonia
Pseudomonas auriginosa- can make green pigment by pyocyanin
Septate hyphae with dichotomous branching
Aspergillus
Antiepleptic drugs effect on bone
Phenytoin, carbamazepine, and phenobarbital are associated with decreased bone density and risk of osteoporosis
Anopheles vector for
Malaria. Its endemic in Thailand, and can lead to intraerythrocytic ring inclusions. It has typical incubation period of weeks.
Swimmin in pond: etiology
Mycobacterium scrofulaceum
