Case 1 Posting 2

Subject: MMIC
Case: Case 1 - Khong Fay Seah
Complaints: Fever, chills, dysuria,
Diagnosis: Urinary Tract Infection

List of Organisms	Tests Required to Identify	Expected Test Results	Treatment
Escherichia Coli	Culture Gram stain and Microscopy Biochemical test test – TSI, IMViC (Indole, Methyl red, Voges-Proskauer, citrate), motility	Lactose-fermenting (Yellow colonies in CLED); Flat, grey colonies on BAP Gram-negative bacilli Biochemical test TSI - Acid slant acid butt with gas but no H2S Indole – Positive (Bright red interface) Methy red – Positive (Red) Voges-Proskauer - Negative Citrate – Negative (Remains green)Motility – Motile (Turbidity out of line of inoculation stab)	Trimethoprim-sulfamethoxazole ampicillin
Klebsiella spp.	Culture Gram stain and Microscopy Catalase test Biochemical test – IMViC (Indole, Methyl red, Voges-Proskauer, citrate), motility	Lactose-fermenting (Yellow colonies in CLED); Mucoid, convex, white colonies on BAP Gram-negative bacilli Positive catalase test (Effervescence) 1) Biochemical test Indole – Negative (No colour change) Methy red – Negative (Yellow) Voges-Proskauer – Positive (Colour change) Citrate – Positive (Deep blue)Motility – Nonmotile (Growth along stab line)	Cephalosporins Aminoglycosides
Streptococcus spp.	Culture Gram stain and Microscopy Catalase test	Lactose-fermenting (Yellow colonies in CLED); Small, white colonies on BAP Haemolysis: α-haemolytic: eg. Streptococcus pneumoniae β-haemolytic: Streptococcus group A, B etc Non-haemolytic: E.g. Enterococcus spp.(Greyer appearance) Gram-positive cocci Negative catalase test	Penicillin Eryhromycin Aminoglycoside
Staphylococcus spp. Eg. S saprophyticus, Staphylococcus aureus	Culture Gram stain and Microscopy Catalase test	Lactose-fermenting (Yellow colonies in CLED); Small, white colonies on BAP Can be hemolytic positive or negative Gram-positive cocci Positive catalase test (effervescence)	Penicillins /with clavulanic acid Cephalosporins Vancomycin
Pseudomonas spp.	Culture Gram stain and Microscopy Oxidase test Biochemical test - TSI	Non-lactose-fermenting; Swarms on BAP; Spready colonies on CLED; Pungent smell Gram-positive bacilli Positive oxidase test Biochemical testTSI - Alkaline slant acidic butt	Penicillin Aminoglycoside
Proteus spp.	Culture Gram stain and Microscopy Oxidase test Biochemical test - TSI, Urease	Non-lactose-fermenting; Swarms on BAP; Glossy colonies; Pungent smell Gram-negative bacilli Negative oxidase test 1) Biochemical test TSI - Alkaline slant acidic butt with H2SUrease – Positive (Purple/pink)	Aminoglycosides Trimethoprim-sulfamethoxazole Ampicillin Cephalosporins
Candida spp.Eg. Candida albicans	Culture Gram stain and Microscopy	Non-lactose-fermenting; Small, flat, white colonies on BAP and CLED; Slightly spready, not glossy Fungus; pseudohyphae	-
Enterococcus faecalis	Culture Gram stain and Microscopy Catalase test Biochemical test – Motility, Indole	Large white colonies; alpha-, beta-, nonhemolytic colonies Gram-positive cocci Negative catalase test Biochemical test Motility – Nonmotile (Growth along stab line)Indole – Negative (No colour change)	Penicillin Vancomycin Gentamicin
Morganella	Culture Gram stain and Microscopy	Large, gray, moist colonies (beta haemolytic) Gram-negative bacili	Aminoglycosides Trimethoprim-sulfamethoxazole
Serratia	Culture Gram stain and Microscopy Catalase test Biochemical test – IMViC (Indole, Methyl red, Voges-Proskauer, citrate), motility	Lactose-fermenting but may produce negative results; Red-pigmented colonies Gram-negative bacilli Positive catalase test (effervescence) 1) Biochemical test Indole – Negative Methy red – Variable Voges-Proskauer - Positive Citrate – PositiveMotility – Motile (Turbidity out of line of inoculation stab)	Cephalosporins Aminoglycosides

Photos of Various Microorganism on Agar Plates:
E.Coli
Klebsiella spp.
Pseudomonas & Klebsiella spp.
Proteus spp.
Candida spp.


Photos are taken by our bacteriology group to "xinjiapo"-GH (Andre,Azhar,Valerie,Boonching)

References:
1. MedlinePlus. (2007) Urinary Tract Infection. Retrieved December 02, 2007, from http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm > >urinary tract infection
2. MedicineNet, Inc. (2007) Definition of Dysuria. Retrieved December 02, 2007, from http://www.medterms.com/script/main/art.asp?articlekey=3163
http://www.medterms.com/script/main/hp.asp > dysuria
3. Levinson, W. (2006). Review Of Medical Microbiology and Immunology. (9th ed.). US: The McGraw-Hill Company

Boon Ching
TG01

MMIC CASE 6

Particulars of Patient
Name: Wong Fei Fei
Sex: Female
Age: 37
Complaints: Fever, pain during urination, vaginal discharge

List of possible organism	Test required	Expected results	treatment
Bacteria Pseudomonas aeruginosa	1) Gram Stain 2) Biochmical Tests: - Catalase test - Oxidase test - TSI agar test 3) Aerobic culture on plates like MacConkey agar plate, blood agar plate or differential media 4) Antibiotic Susceptibility (aminoglycoside + penicillin)	1) Shows gram negative rod 2) Catalase and oxidase positive TSI medium no colour change (K/K/g-/H2S-) 3) Colourless colonies on MacConkey plateColonies grown on blood agar.	Antibiotics that have activity against P. aeruginosa include: - aminoglycosides - quinolones (ciprofloxacin) - cephalosporins (ceftazidime and cefoperazone)
Escherichia coli	1) Gram Stain 2) Biochemical Tests: - TSI agar test - Methyl red test - VP reaction test - Citrate test 3) Aerobic culture on MacConkey agar or EMB agar (or both), blood agar 4) Serology is done using the SSS-Coagglutination test 5) Antibiotic Susceptibility (fluoroquinolone)	1) Gram negative rods 2) • Grows on TSI slant with a (A/A/g+/H2S-) profile • Indole (+) • Methyl red (+) • VP (-) • Citrate (-) 3) On MacConkey agar, deep red colonies are produced. Growth on EMB agar would show black colonies with greenish-black metallic sheen. Hemolysis on blood agar 4) Serology detects O55:K5:H21	Antibiotics which may be used to treat E. coli infection: - nitrofurantoin - fluoroquinolones - meropenem - aminoglycosides - ciprofloxacin
Enterococcus spp.	1) Gram Stain 2) Biochemical tests: - Catalase test 3) Antibiotic Susceptibility (gentamicin + vancomycin)	1) Cocci in tetrad and clusters 2) (-) to weakly (+) catalase	Can treat with vancomycin and gentamicin
Proteus mirabilis	1) Gram stain 2) Biochemical tests: - Indole test - Methyl red test - VP test - Catalase test - Oxidase test - Urease test 3) Aerobic culture on XLD plate, blood agar or differential media 4) Antibiotic Susceptibility (ampicillin)	1) Gram negative rod 2) Indole test (-) Methyl red (+) VP (-) Catalase (+) Oxidase (-) Urease (+) 3) Colonies growns on the agar plates	Antibiotics which may be used to treat: - ampicillin - aminoglycoside - TMP-SMZ - fluoroquinolone - cephalosporin
Chlamydia Trachomatis	1) McCoy cell culture 2) Fluorescent Antibody test/Enzyme-linked Immunoassay 3) DNA probe test 4)Antibiotic Susceptibility (Doxycycline or azithromycin)	1) Cytoplasmic inclusions observed by immunofluore-scence after few days of incubation in cell culture 2) Detect the presence of genus-specific lipopolysaccharide antigen	Can be cured with antibiotics like: - Azithromycin - Doxycycline - Tetracycline
Neisseria Gonorrhoeae	1) Gram stain 2) Biochemical Test - Oxidase test 3) Serology Antibiotic Susceptibility (Penicillin)	1) Gram negative, diplococcus 2) Oxidase (+) IgG and IgA antibodies against gonococcal pili, outer membrane proteins and LPS detected	Recommended treatment: - cephalosporin - Fluoroquinolone plus an antibiotic e.g. ceftriaxone, cefixime, ciprofloxacin
Klebsiella pneumoniae	1) Gram stain 2) Biochemical test: - Citrate test - VP test 3) Aerobic culture on blood agar, MacConkey agar and differential media 4) Antibiotic susceptilibilty (cephalosporin)	1) Gram negative, large and regular capsules 2) Citrate (+) VP (+) 3) Large colonies and very mucoid	Can be cured with antibiotics like: - cephalosporine - aminoglycoside - imipenem
Providencia species	1) Gram stain 2) Biochemical test: - Urease test 3) Aerobic culture on blood agar and differential media 4) Antibiotic susceptilibilty (ceftazidime and cefepime)	1) Gram negative 2) Urease (-) 3) Circular, convex, smooth colonies	Recommended treatment with: - ceftazidime - cefepime - aztreonam - imipenem
Citrobacter	1) Gram stain 2) Aerobic culture on blood agar and differential media 3) Biochemical test:Citrate test	1) Gram negative 2)Circular, convex, smooth colonies 3) Citrate (+)	Antibiotics which may be used to treat: - ampicillin - cephalosporins - fluoroquinolones
Viruses Herpes simplex virus type 2 (HSV-2)	1) Virus isolation using inoculation of tissue culture 2) Serology	1) Viral DNA identified 2) Antibodies of HSV-2 detected	Several antiviral drugs are effective against such infection: - Acyvlovir - Valacyclovir - Vidarabine
Parasites Trichomonas vaginalis	1) Microscopic examination – vaginal discharge examined microscopically in a drop of saline 2) Anaerobic culture	1) Characteristic motile trichomonads observed in wet mount 2) Colonies growth on agar plates	Successful treatment requires destruction of trichomonads by medicine like: - metronidazole (e.g. Flagy) - tinidazole and ornidazole
Fungi Candida albicans	1) Potassium hydroxide (KOH) preparation of the vaginal discharge 2) Culture on fungal or bacteriologic media at room temperature or 37oC	1) Hyphae and pseudo spores of Candida are visible under microscopic examination 2) Culture medium is incubated for several days, during which time colonies of yeast and/or bacteria develop	Usually treated with antimycotics—antifungal drugs e.g. topical clotrimazole, topical nystatin, fluconazole, and topical ketoconazole

Images of possible microorganisms:


Pseudomonas aeruginosa on mac conkey plate (1)

P. mirabilis on an XLD agar plate (2)

C. trachomatis inclusion bodies (brown) in a McCoy cell culture (3)

trichomonas vaginalis wet mount (4)

Candida albicans (4)

K. pneumoniae on a MacConkey agar plate (5)

References:
1. http://www.austincc.edu/microbugz/html/ > macconkey_agar
2. http://en.wikipedia.org/wiki/Main_Page > Proteus_mirabilis
3. http://en.wikipedia.org/wiki/Main_Page > Chlamydia_trachomatis
4. http://www.google.com/ > image search > "microorganism name"
5. http://en.wikipedia.org/wiki/Main_Page > Klebsiella_pneumoniae

Doreen Ng (TG 01)

Case 3 2nd Post

Possible Micro-organism	Microscopy	Culture	Biochemical Tests	Antibiotics Sensitivity Testing	Treatment
Escherichia Coli	Gram negative bacilli	Mac Conkey: Lactose Fermenting(Pink) Sheep Blood Agar: β-hemolytic	TSI: acidic slant/ acidic deep Oxidase Test: Negative IMViC: ++-- Urease Test: Negative	Sensitive to amoxillin, cephalosporins, carbapenems, aztreonam, trimethoprim-sulfamethoxazole, ciprofloxacin, nitrofurantoin, aminoglycosides	No drug is normally needed. Amoxillin used when needed.
Proteus spp.	Gram negative bacilli	Mac Conkey: Non-Lactose Fermenting(colourless) Sheep Blood Agar: Spreading Growth	TSI: alkaline slant with black ppt Oxidase Test: Negative IMViC: ++-+* Urease Test: Positive	Resistance to tetracycline, first generation cephalosporins and ampicillins	Most antibiotics can be used other then the 3 that it is resistant to.
Klebsiella spp.	Gram negative bacilli	Mac Conkey: Lactose Fermenting(Red) Growth in areobic and anareobic condition	TSI: alkaline slant/ acidic deep Oxidase Test: Negative IMViC: --++ Urease Test: Negative	Susceptible to aminoglycosides cephalosporin, gentamicin Resistance to carbenicillin, ampicillin, quinolones, and increasingly to ceftazidime	Genamicin
Serratia	Gram negative bacilli	Mac Conkey: Non-Lactose Fermenting(Colourless)	TSI: acid slant/ acid deep Oxidase Test: Negative IMViC: +-++ Urease Test: Negative	Suceptible to anitbiotics carbapenems, cephalosporin, amikacin Resistant to gentamicin and tobramycin	Carbapenems, cephalosporin, amikancin
Pseudomonas	Gram positive bacilli	Mac Conkey: Non-Lactose Fermenting(colourless)	TSI: alkaline slant/ alkaline deep Oxidase Test: Positive Catalase Test: Positive	Susceptible to piperacillin, imipenem, tobramycin, ciprolorxacin Resistant to penicillin	Tobramycin
Enterococcus	Gram positive cocci	Mac Conkey: Lactose Fermenting(Pink) Sheep Blood Agar: No Haemolysis	Catalase test: Negative	Resistant to Quinupristin, ampicillin and vancomycin	Vancomycin

*Mostly Proteus strain positive except P. mirabilis negative.

Urease Test: Positive - Pink, Negative - Orange

Oxidase Test: Positive - Dark Maroon to Black, Negative - Slight pink colouration or no colouration

IMViC: Indole Test, Methyl Red, Voges-Proskauer, Citrate test. Done when oxidase test is negative.

Indole Test: converts tryptophan into indole, ammonia and pyruvic acid. Bacterial culture grown in tryptophan or peptone for 24 to 48 hours before adding kovac reagent. Positive-Red, Negative- Yellow

Methyl Red Test: If the organism uses the mixed acid fermentation pathway and produces stable acidic end-products, the acids will overcome the buffers in the medium and produce an acidic environment in the medium. When methyl red is added, if acidic end products are present, the methyl red will stay red.

Voges-Proskauer: When the VP reagents are added to MR-VP broth that has been inoculated with an organism that uses the butylene glycol pathway, the acetoin end product is oxidized in the presence of potassium hydroxide (KOH) to diacetyl. Creatine is also present in the reagent as a catalyst. Diacetyl then reacts to produce a red color. Therefore, red is a positive result. If, after the reagents have been added, a copper color is present, the result is negative.

Citrate Test: To see if bacteria is able to use only citrate as carbon and energy source. Positive-Blue, Negative- Green.

Reference:

http://www.wikepedia.com/

Douglas
0503224H
TG01

MMIC CASE 4 (2nd posting)

Particulars of patient
Name: Tong Wei Hong

Sex: Male

Age: 68 years

Clinical diagnosis
Complaints: Fever, chills, excessive phlegm, breathing problems

Diagnosis: Bronchitis

Possible Microorganisms	Description	Microscopy	Culture	Biochemical Tests
Streptococcus pneumoniae	- Gram-positive - Alpha-hemolytic diplococcus bacterium - Fermentative aerotolerant anaerobe - Members of the genus Streptococcus - Found in the nasopharynx - Major cause of pneumonia	Gram stain: Gram positive, lancet-shaped diplococcus (stained purple)	1) Blood agar plate (BAP) with added optochin antibiotic disk: alpha-hemolytic (green) colonies and a clear zone of inhibition around the disk	1) Catalase test: Catalase-negative
Haemophilus influenzae	-Non-motile gram-negative coccobacillus -Found in the upper respiratory system of humans -Major cause of lower respiratory tract infections, associated with pneumonia	Gram stain: Gram negative coccobacilli, with no specific arrangement (stained pink)	1) Chocolate agar (with factor X (heme) and factor V (NAD)): Flat, greyish-brown colonies colonies with diameters of 1-2mm	1) Catalase test: Catalase-positive 2) Oxidase test: Oxidase-positive
Moraxella catarrhalis	-Gram-negative, non-motile, aerobic, oxidase-positive diplococcus cocci -Produce beta-lactamase -Major cause of respiratory tract-associated infection, associated with bronchopneumonia	Gram stain: Gram negative kidney bean shaped diplococcus (stained pink)	1) Enriched media (e.g. Mueller-Hinton, modified Thayer-Martin): Non-pigmented or pinkish-grey opaque colonies 2) Chocolate blood agar: Opaque and non-hemolytic colonies being pushed along the surface of the agar like a hockey puck	1) Oxidase test: Oxidase-positive 2) Catalase test: Catalase-positive
Mycoplasma pneumoniae	-Small bacterium lacking a peptidoglycan cell wall -Member of the class Mollicutes -Uniform granular appearance	Nil	Nil	Nil
Chlamydia pneumoniae	-Small bacterium -Produces round, dense, glycogen-negative inclusion -Elementary bodies with pear-shaped appearance	Nil	Nil	Nil
Bordetella pertussis	-One of Bordetella species -Minute gram-negative, aerobic coccobacillus	Gram stain: Gram negative coccobacilli, with no specific arrangement (stained pink)	1) Enriched media- Bordet-Gengou medium (potato-blood-glycerol agar) or BCYE plate that contains penicillin G, using immunofluorescence staining: Mercury-drop colonies Small, faintly staining gram-negative rods	1) Urease test - Urease-negative 2) Nitrase test - Nitrase-negative 3) Citrate test - Citrate-negative 4) Oxidase test - Oxidase-positive

Possible Microorganisms	Serology	Others	Antibiotic Susceptibility Test	Treatment
Streptococcus pneumoniae	Nil	1) Bile solubility: Colonies soluble in bile 2) Capsule swelling test (Quellung reaction): Capsular swelling in the presence of antisera; Quellung reaction-positive	-Resistant to cephalosporins, macrolides (such as erythromycin), tetracycline, clindamycin and the quinolone -Susceptible to Vancomycin	Vancomycin in combination with β-lactam antibiotics
Haemophilus influenzae	Nil	Nil	Susceptible to ampicillin, cephalosporins, cefotaxime	Ampicillin (or amoxicillin) if β-lactamase-negative; cefotaxime (IV) or ceftriaxone
Moraxella catarrhalis	Nil	1) Deoxyribonuclease (DNase) test: Presence of DNase 2) Nitrate reduction test: Nitrate and nitrite levels are reduced.	Susceptible to trimethoprim-sulfamethoxazole, fluoroquinolones, cephalosporins, amoxicillin-clavulanic acid	Trimethoprim-sulfamethoxazole, amoxicillin-clavulanic acid, fluoroquinolones or cephalosporins
Mycoplasma pneumoniae	1) Complement-fixation test: Detects both IgG and IgM specific to M. pneumoniae. A four-fold rise in complement fixation titer during the acute and convalescent phases is indicative of a M. pneumoniae infection. 2) Hemagglutination test: Positive blood test for cold-hemagglutinins A titer of 1:64 or more indicates infection of M. pneumoniae 3) Enzyme immunoassay: Presence of M. pneumoniae specific IgM	Nil	Susceptible to Macrolide antibiotics, doxycyclin, second generation quinolones, tetracyclines, erthromycin	Macrolide antibiotics, doxycyclin, second generation quinolones, tetracyclines, erthromycin
Chlamydia pneumoniae	1) Direct Fluorescent Antibody Test: Detection of IgM or IgG antibodies – a fourfold rise in either the IgM or IgG titers Presence of proteins (antigens) from Chlamydia pneumoniae	Nil	Susceptible to macrolides, tetracycline, fluoroquinolones, erythromycin, clarithromycin	Macrolides, tetracycline, fluoroquinolones, erythromycin, clarithromycin
Bordetella pertussis	1) Direct Fluorescent Antibody (FA) Test: Presence of antibodies Presence of proteins (antigens) from Bordetella pertussis	Nil	Susceptible to erythromycin	Erythromycin

Pictures of Possible Microorganisms:

Streptococcus pneumoniae on blood agar showing alpha hemolysis (green zone surrounding colonies). Note: the zone of inhibition around a optochin disk.

Streptococcus pneumoniae gram stain of a film of sputum

Streptococcus pneumoniae - Quellung (capsular swelling) reaction

Gram stain of Haemophilus influenzae

Haemophilus influenzae on chocolate agar

Moraxella catarrhalis on chocolate agar

Moraxella catarrhalis on BAP

Gram stain of Moraxella catarrhalis

Electron micrograph of Mycoplasma pneumoniae

Chlamydial inclusions containing pear-shaped C. pneumoniae elementary bodies. EB, elementary body; FG, fatty globules; N, nucleus

Photomicrograph of Bordetella pertussis bacteria using gram staining technique

References
1. http://www.google.com/ > image search > "microorganism name"
2. http://en.wikipedia.org/wiki/Main_Page > "microorganism name"
3. http://www.textbookofbacteriology.net/ > S.pneumoniae
4. Geo.F.Brooks, Janet S.Butel, Stephen A. Morse. (2004). Jawetz, Melnick, & Adelberg's Medical Microbiology Twenty-third Edition. Singapore: The McGraw-Hill Companines, Inc

Dorothy Png
TG01
0503239F

MMIC PBL Case 2 (2nd Post)

Name: Kwan Siew Yan (outpatient)
Sex: Female
Age: 29
Complaints: Diarrhea
Diagnosis: Enterocolitis
Antibiotic treatment (if any): Nil
Specimen: Stool

Possible Organisms
1) Salmonella enteritidis
2) Shigella species
3) Campylobacter jejuni
4) Staphylococcus aureus
5) Clostridium difficile
6) Bacillus cereus
7) Enteroinvasive E coli (EIEC)

Investigation required:
1) Culture
2) Microscopy
3) Biochemical tests
4) Serology; ELISA and cytotoxicity tests
5) Antibiotic susceptibility tests

Possible Microorganisms	Culture	Microscopy	Biochemical Tests
Salmonella enteritidis	-MacConkey’s agar: non-lactose fermenting (colourless) colonies -Salmonella-shigella agar: colonies with black centre due to H2S production	-gram-negative rods - motile	-TSI agar test: alkaline slant and acid butt with gas and H2S -IMViC tests: gives test result of - + - + respectively.
Shigella species	-MacConkey’s agar: same as Salmonella enteritidi-Salmonella-shigella agar:colonies without black centre as no H2S is produced	-gram-negative rods - non-motile	-TSI agar test: alkaline slant and acid butt with no gas, no H2S
Campylobacter jejuni	-campylobacter selective media (e.g. Skirrow medium or Campy BAP): grow in scanty amounts at 42 degrees celsius	-curved, gram-negative rods that appear either comma or S-shaped -motile with a single polar flagellum	-positive oxidase test
Staphylococcus aureus	-Blood agar: yellow or gold colonies	-gram-positive cocci in clusters	-catalase-positive -coagulase-positive
Clostridium difficile	- Blood agar	- gram-positive -spore-forming rods	Not done
Bacillus cereus	- Blood agar	- gram-negative -spore-forming rod	Not done
Enteroinvasive E coli (EIEC)	-MacConkey’s agar: lactose-fermenting colonies	-gram-negative rods	-TSI agar test: alkaline slant and acid butt with gas, no H2S - IMViC tests: gives test result of + + - - respectively

Possible Microorganisms	Serology; ELISA and cytotoxicity tests	Antibiotic susceptibility tests	Treatment
Salmonella enteritidis	Not done	-resistant to ampicillin and chloramphenicol	-enterocolitis is self limiting in 2-3 days, thus antibiotic treatment is not required.
Shigella species	Not done	-susceptible to ciprofloxacin, ampicillin, doxycycline and trimethoprim-sulfamethoxazole	-fluid and electrolyte replacement without antibiotics or - one of the following antibiotics: ciprofloxacin, ampicillin, doxycycline and trimethoprim-sulfamethoxazole
Campylobacter jejuni	Not done	-susceptible to erythromycin	- usually symptomatic treatment only; erythromycin for severe disease
Staphylococcus aureus	Not done	- susceptible to penicillin G, nafcillin and vancomycin	-penicillin G for sensitive isolates -nafcillin is used to treat beta-lactamase resistant strains -vancomycin is used to treat isolates resistant to nafcillin
Clostridium difficile	-Exotoxin in stool detected by cytopathic effect on cultured cells. Identified by neutralization of cytopathic effect with antibody -Assessment of the A and B toxins in stool can be detected by using ELISA	-susceptible to metronidazole	-metronidazole. Vancomycin, although effective, should not be used as it may select for vancomycin-resistant enterococci
Bacillus cereus	Not done	-susceptible to vancomycin, chloramphenicol, gentamicin, tetracyclines or sulfonamides	-only symptomatic treatment is given antibiotics such as vancomycin, chloramphenicol, gentamicin, tetracyclines or sulfonamides
Enteroinvasive E coli (EIEC)	Not done	- susceptible to trimethoprim-sulfamethoxazole, aminoglycoside, ampicillin, cephalosporin and sulfonamides	- treatment can be difficult because of multiple drug resistance as mediated by ``R’’ plasmid

MacConkey’s agar is a selective and differential media used to differentiate between Gram negative bacteria while inhibiting the growth of Gram positive bacteria. The addition of bile salts and crystal violet to the agar inhibits the growth of most Gram positive bacteria, making MacConkey agar selective. Lactose and neutral red are added to differentiate the lactose fermenters, which form pink colonies, from lactose nonfermenters that form clear colonies. [2]

Salmonella-shigella agar are designated as moderately selective media based upon the degree of inhibition of gram-positive microorganisms that they inhibit due to their content of bile salts, brilliant green and citrates. [3] This media is used to find out whether the suspected microorganism is either Salmonella enteritidis or Shigella sp.

Skirrow’s agar is peptone and soy protein base agar supplemented with lysed horse blood and vancomycin (inhibits Gram-positives), polymyxin B (antifungal), and trimethoprim (broad spectrum). Campy BAP is brucella agar supplemented with sheep blood and vancomycin, trimethoprim and cephalothin (inhibits streptococci) [4]

Blood agar is an enriched, differential media used to isolate fastidious organisms and detect hemolytic activity. β-hemolytic activity will show complete lysis of red blood cells surrounding colony, while α-hemolysis will only partially lyse hemoglobin and will appear green. γ-hemolysis (or non-hemolytic) is the term referring to a lack of hemolytic activity. [2].

After the microorganisms had been isolated, microscopy is used to observe the morphological characteristics so that to identify the organism. Gram stain is a method of differentiating bacterial species into two large groups (Gram-positive and Gram-negative) based on the chemical and physical properties of their cell walls. Gram-positive bacteria have cell wall made of peptidoglycan which stains purple and Gram-negative bacteria which stain pink. [5]. Spore stain will be required to identify spores. Wet mount microscopy is used initially before isolation of organisms to identify their motility.

Antibiotic Susceptibility Test, also known as Kirby-Bauer test, is performed by swabbing the bacterium on the agar and the antibiotic discs are placed on top. The antibiotic diffuses from the disc into the agar in decreasing amounts the further it is away from the disc. If the organism is killed or inhibited by the concentration of the antibiotic, there will be no growth in the immediate area around the disc. This is called the zone of inhibition. The zone sizes are looked up on a standardized chart to give a result of sensititive, resistant, or intermediate. [6] This can help to provide the necessary treatments for the patient.

Pictures
Salmonella enteritidis on Salmonella-shigella agar
[7]


[8]


Staphylococcus aureus (gram stain)
[9]

Campylobacter jejuni wet mount microscopy[10]


Clostridium difficile (gram stain)[11]


Bacillus cereus on blood agar[12]


Enteroinvasive E coli (EIEC)on MacConkey agar[13]













References
1) Levinson, W. (2006). Review Of Medical Microbiology and Immunology. (9th ed.). US: The McGraw-Hill Company
2) http://en.wikipedia.org/ >Agar_plate
3) http://www.bd.com/ >SS_Agar
4) http://www.life.umd.edu/ >Media
5) http://en.wikipedia.org/ >Gram_stain
6) http://www.rlc.dcccd.edu/ >antibiotics
7) http://www.rci.rutgers.edu/ >salmonellashigella
8) http://textbookofbacteriology.net/ >Shigella
9) http://en.wikipedia.org/ >Staphylococcus_aureus
10) http://www.umm.edu/ >fecal culture
11) http://en.wikipedia.org/ >Bacillus_cereus
12) http://www.spiceisle.com/ > Enteric demonstration

Soong Ci Liang
TG01
0503333G

MMIC laboratory diagnosis

Patient particulars:

Name: Wong Fei Hong

Sex: Male

Age: 37 years

Complaints: fever sewlling around operation wound

Diagnosis: wound infection

List of possible organism	Test required	Expected results	treatment
Corynebacterium diphtheriae	1) Gram stain 2) Methylene blue 3) Culture (Loffler medium followed by tellurite plate) 4) PCR assay	1) gram-positive, highly pleomorphic organisms with no particular arrangement 2) Demostrate the presence of metachromatic granules 3) If C. diphtheriae is presence, tellurium in the medium will be reduced to elemental tellurium by the organism, showing a grap-black color of tellurium in the colony 4) Identify the toxin gene presence in the organism isolated form the patient	Antitoxin penicillinG Erythromycin
Pseudomonas aeruginosa	1) Gram stain 2) Culture (EMB or MacConkey’s agar) 3) TSI medium 4) Biochemical test (catalase, oxidase, nitrase, lipase)	1) Gram negative rod with no particular arrangement 2) Culture of patient specimen on MacConkey’s agar produce colourless colonies as the organism does not ferment lactose 3) Alkaline slant and an alkaline butt as the organism does not ferment lactose 4) Catalase, Oxidase, Nitrase and Lipase positive	Antipseudomonal penicillin Aminoglycoside
staphylococcuss aureus	1) Gram stain 2) culture (Mannitol salt agar) 3) coagulase test 4)biochemical test (catalase test)	1) Gram positive cocci in grapelike clusters 2) Golden yellow colonies 3) coagulase positive 4)catalase positive	Mupirocin Beta-lactamose resistant penicillins such as nafcillin, cloxacillin, cephalosporins or vancomycin
Proteus mirabilis	1) Gram stain 2) culture (EMB or MacConkey’s agar)3) TSI agar 4) biochemical test (indole test	1) Gram negative rod 2) Non-lactose fermenting colonies on EMB or MacConkey’s agar 3) alkaline slant and acid butt. 4) indole negative	Ampicillin Tetracycline
group A streptococcus bacterium	1) Gram stain 2) Culture (blood culture) 3) Biochemical test (indole test)	1) Gram positive cocci in chain 2) Beta hemolytic colonies 3) Indole test negative	Penicillin G
Bacteroides fragilis	1) Gram stain 2) Anaerobic Culture blood agar plates containing kanamycin and vaomyycin 3) TSI agar	1) Gram negative rod 2) Colonies should be able to grow on the BAP containing the anitbiotic 3) Red stunt yellow butt	Penicillin G Cephalosporins Aminoglycosises Metronidazole
Pasteurella Multocida	1) Gram stain 2) Culture (blood agr or chocolate agar) 3) oxidase test 4) catalase test	1) Encapsulated gram negative rod 2) positive 3) positive 4)positive	Penicillin G
Aeromonas Hydrophila	1) Gram stain 2) Culture (Sheep blood agar with ampicillin) 3) catalse test 4) oxidase test	1) Gram negative rod 2) Aeromonas Hydrophila is able to grow on the agar plate while the ampicillin will inhibit the grow of other competing organism 3) positive 4) positive	chloramphenicol
Clostridium perfringens	1) Gram stain 2) Culture ( blood agar)	1) Large gram postitive rods 2) Exhibit a double zone of hemolysis	Penicillin G

Types of wound infection and their causative agents:

-Skin infection at the site of preexisting skin leison: Corynebacterium diphtheriae

-Burn wound infection: Pseudomonas aeruginosa

-Wound infection in diabetic patients: Staphylococcuss aureus

-Surgical wound infection: Staphylococcuss aureus

-Abcess infection of brain, lung or abdominal: Bacteroides fragilis

-Wound infection caused by cats or dog bite: Pasteurella multocida

-Traumatic open wound infection: Aeromonas hydrophila

-Gas gangrene wound infection: Clostridium perfringens

Reference:

1) Levinson, W. (2006). Review Of Medical Microbiology and Immunology. (9th ed.). US: The McGraw-Hill Company

Wing Fat

Tg01

Compilation of All Potential Microorganisms To Each Case

	Diagnosis	Potential Pathogens	Descriptions
Case 1	Urinary Tract Infection (UTI)	1) Escherichia Coli 2) Klebsiella spp. 3) Streptococcus spp. (GPC) 4) Staphylococcus spp. (GPC) Eg. S saprophyticus, Staphylococcus aureus 5) Pseudomonas spp. 6) Proteus spp. 7) Candida spp. Eg. Candida albicans 8) Enterococcus 9) Morganella 10) Serratia	1) Gram-negative bacilli 2) Gram-negative bacilli 3) Gram-positive cocci 4) Gram-positive cocci 5) Gram-positve bacilli 6) Gram-negative bacilli 7) Gram-negative bacilli 8) Fungus 9) Gram-positive cocci 10) Gram-negative bacilli 11) Gram-negative bacilli
Case 2	Enterocolitis	1) Salmonella enteritidis 2) Shigella species 3) Campylobacter jejuni 4) Staphylococcus aureus 5) Clostridium difficile 6) Bacillus cereus 7) Enteroinvasive Escherichia coli (EIEC)	1) Gram-negative rods 2) Gram-negative rods 3) Gram-negative rods 4) Gram-positive cocci in clusters 5) Gram-positive rods 6) Gram-negative rods 7) Gram-negative rods
Case 3	Urinary Tract Infection (UTI)	1) Escherichia Coli 2) Proteus spp. 3) Klebsiella spp. 4) Serratia 5) Proteus 6) Pseudomonas spp. 7) Streptococcus spp. 8) Enterococcus 9) Candida spp. (Fungus)	1) Gram negative bacilli 2) Gram negative bacilli 3) Gram negative bacilli 4) Gram negative bacilli 5) Gram negative bacilli 6) Gram positive bacilli 7) Gram positive cocci 8) Gram positive cocci 9) -
Case 4	Bronchitis	1) Streptococcus pneumoniae 2) Haemophilus influenzae 3) Moraxella catarrhalis	1) Gram-positive cocci 2) Gram-negative coccobacillus 3) Gram-negative diplococci
Case 5	Wound Infection	1) Corynebacterium diphtheriae 2) Pseudomonas aeruginosa 3) Staphylococcuss aureus 4) Proteus mirabilis	1) Gram positive 2) Gram negative rod 3) Gram positive coccus 4) Gram negative rod
Case 6	Urinary Tract Infection (UTI)	1) Escherichia coli 2) Proteus 3) Chlamydia 4) Gonorrhea 5) Herpes simplex virus type 2 (HSV-2) 6) Candida 7) Parasites

MMic PBL Case 3

MMic PBL



Name: Maisy Hong

Sex: Female

Age: 67

Complaints: Fever, chills, bladder distension; on indwelling catheter
(Bladder distention on indwelling catheter: this refers to implanting a flexible or rigid hollow tube to distend body passages, or to drain fluids from body cavities. [1] )


Diagnosis: Urinary Tract Infection
(A urinary tract infection, or UTI, is an infection that can happen anywhere along the urinary tract. The urinary tract includes the bladder, kidneys, ureters and urethra.[2])

Antibiotic treatment (if any): Nil

Specimen: Urine

Gram	Shape	Possible Microorganism
Negative	bacilli	Escherichia Coli
Negative	bacilli	Proteus spp.
Negative	bacilli	Klebsiella spp.
Negative	bacilli	Serratia
Negative	bacilli	Proteus
Positive	bacilli	Pseudomonas spp.
Positive	cocci	Streptococcus spp.
Positive	cocci	Enterococcus
-	-	Candida spp. (Fungus)

Identification of Microorganism

1. Gram staining and microscopy.
2. Catalase Test.
3. Oxidase Test.
4. Biochemical Test.
5. Aerobic culture on sheep blood agar, Cysteine Lactose Electrolyte Deficient Medium, and Mac Conkey agar.
6. Antibiotics sensitivity testing.

Reference

[1] http://dictionary.reference.com/
[2]MedlinePlus. (2007) Urinary Tract Infection. Retrieved December 02, 2007, from http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm>urinary tract infection

Douglas
TG01

MMIC

Name: Wong Fei Hong
Sex: Male
Age: 37
Complaints: Fever, swelling around operation wound
Specimen: Wound swab
Diagnosis: Wound infection

A wound infection happens when pathogens enter an open wound of the patient. Factors such as disease, surgery and weak immune system increase the patient’s risk of getting wound infection. Signs and symptom of a wound infection includes:
-Redness or swelling around the wound
-Secretion of Pus or watery discharge around the wound area
-foul odour from the wound
-mild fever

Possible pathogens that cause wound infection:
-Corynebacterium diphtheriae
-Pseudomonas aeruginosa
-staphylococcuss aureus
-Proteus mirabilis

Corynebacterium diphtheriae: C. diphtheriae is a facultative anaerobic, gram positive organism that can infect skin lesions in people with poor skin hygiene, causing cutaneous diphtheria. Symptom of cutaneoud diphtheria includes mild fever and swollen wound.

Pseudomonas aeruginosa: Pseudomonas aeruginosa is an aerobic, gram negative rod shape bacterium that can cause burn infection and wound infection. The microorganism is able to produce endotoxin that causes fever.

Staphylococcuss aureus: Staphylococcuss aureus is a facultative, gram positive coccus organism that causes localised infection in forms of abscess and skin infection, which is one of the possible causes to surgical wound infections.

Proteus mirabilis: Proteus mirabilis is A facultative, gram negative rod proteus species that cause uriniry tract infection, but it can also cause wound infection, mostly in hospitalized patients.

Laboratory diagnosis:
-Gram stain
-Culture (aerobic/anaerobic)
-biochemical reactions
-oxidase tests
-catalase tests
-antibiotic susceptibility

Wing Fat
Tg01

MMIC PBL

Particulars of patient
Name: Tong Wei Hong
Sex: Male
Age: 68 years

Clinical diagnosis
Complaints: Fever, chills, excessive phlegm, breathing problems
Diagnosis: Bronchitis

Bronchitis is inflammation of the large airways that branch off the trachea (bronchi), usually caused by infection but sometimes caused by irritation from a gas or particle.

In bronchitis, areas of the bronchial wall become inflamed and swollen, and mucus increases. As a result, the air passageway is narrowed. Bacteria and viruses are usually present.

There are two main types of bronchitis:

-Acute bronchitis comes on rapidly, usually after a virus has invaded the upper respiratory tract. Sometimes there is a bacterial infection as well. Viruses most likely to trigger acute bronchitis are those responsible for influenza (the flu) or the common cold.

-Chronic bronchitis is defined as excessive mucus secretion in the bronchi and a chronic or recurrent mucus-producing cough that lasts three or more months and recurs year after year. People who have chronic bronchitis are more susceptible to bacterial infections of the airway and lungs, like pneumonia.

Mycoplasma pneumoniae and Chlamydia pneumoniae often cause bacterial bronchitis in young adults. Among middle-aged and older people, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms causing bacterial bronchitis.

Viral bronchitis may be caused by a number of common viruses, including the influenza virus (influenza A and B). A person often has a combination of bacterial and viral bronchitis.

Possible causative agents

The below 3 microorganisms often cause bacterial bronchitis in middle-aged and older people.

Possible Microorganisms	Description
Streptococcus pneumoniae	-Gram-positive -Alpha-hemolytic diplococcus bacterium -Members of the genus Streptococcus -Found in the nasopharynx -Major cause of pneumonia
Haemophilus influenzae	-Non-motile gram-negative coccobacillus -Found in the upper respiratory system of humans -Major cause of lower respiratory tract infections, associated with pneumonia
Moraxella catarrhalis	-Gram-negative, aerobic, oxidase-positive diplococcus cocci -Major cause of respiratory tract-associated infection, associated with bronchopneumonia

Investigation required

Specimen: Sputum
*Clear or white sputum suggests a viral infection; yellow or green sputum suggests a bacterial infection.

• Microscopy
  - Gram stain (Gram positive, -negative)


• Culture
  - Aerobic on blood agar plates
  
• Antibiotic Suspectibility
  
• Serology (detection of viruses)
  - Haemagglutinin Inhibition (HI)
  - Enzyme-Linked ImmunoSorbent Assay (ELISA)
  
• Others
  - Oxidase test (Oxidase-positive, -negative)
  - Catalase test (Catalase-positive, -negative)
  

References

1) http://www.merck.com/mmhe/sec04.html > Bronchitis
2) http://en.wikipedia.org/wiki/Main_Page > Moraxella_catarrhalis
3) http://en.wikipedia.org/wiki/Main_Page > Haemophilus_influenzae
4) http://en.wikipedia.org/wiki/Main_Page > Streptococcus_pneumoniae

Dorothy
TG01

MMIC PBL

Name: Kwan Siew Yan (outpatient)
Sex: Female
Age: 29
Complaints: Diarrhea
Diagnosis: Enterocolitis
Antibiotic treatment (if any): Nil
Specimen: Stool

Enterocolitis is the inflammation of the large and small intestines. [1] It is characterized by an invasion of the epithelial and subepithelial tissue of the small and large intestines. Strains that do not invade do not cause this disease. The organisms penetrate both through and between the mucosal cells into the lamina propria, resulting in inflammation and diarrhea. A polmorphonuclear leukocyte will limit the infection to other parts of the body. [2] Symptoms will include:
- diarrhea
- nausea
- vomiting
- fever
- abdominal bleeding
- rectal bleeding
- sluggishness [1]

Possible Organisms Present [2]:
1) Salmonella enteritidis
Characteristics
- facultative anaerobes
- gram-negative rods
- do not ferment lactose
- produce H2S
- motile

Habitat and Transmission
- found in enteric tract of humans and animals
- transmitted mainly by fecal-oral route and foods prepared by chronic carriers

Pathogenesis
- invade the mucosa of the small and large intestines
- infectious dose is at least 10*5 organisms, much greater than infectious dose of Shigella

2) Shigella species
Characteristics
- facultative gram-negative rods
- do not produce H2S
- non-lactose fermenting
- non-motile compared to Salmonella

Habitat and Transmission
- human colon only; human disease
- no animal reservoir for Shigella
- transmitted by the fecal-oral route
- principal factors in transmission include fingers, flies, food and feces

Pathogenesis
- invade the mucosa of the ileum and colon but do not penetrate further; hence sepsis is rare
- most effective pathogens among enteric bacteria as infectious dose is much lower (1-10 organisms) than that of Salmonella

3) Campylobacter jejuni
Characteristics
- curved, gram-negative rods that appear either comma or S-shaped
- motile with a single polar flagellum
- microaerophilic (5% O2 with 10% CO2)
- grow well at 42℃

Habitat and Transmission
- human and animal feces
- transmitted by fecal-oral route
- Food and water contamination with animal feces is the major source of human infection. (e.g. poultry, meat and unpasteurized milk)

Pathogenesis
- invade mucosa of colon but do not penetrate; hence sepsis is rare

4) Staphylococcus aureus
Characteristics
- gram-positive cocci in clusters
- coagulase-positive and catalase-positive

Transmission
- via the hands

Pathogenesis
- produce enterotoxin in foods

5) Clostridium difficile
Characteristics
- anaerobic
- gram-positive
- spore-forming rods

Habitat and Transmission
- human colon and transmitted by fecal-oral route

Pathogenesis
- antibiotics suppress normal flora of colon, allowing them to overgrow and produce large amounts of exotoxins

6) Bacillus cereus
Characteristics
- aerobic
- gram-negative
- spore-forming rod

Habitat and Transmission
- found in grains such as rice (e.g. re-heated rice)

Pathogenesis
- Two enterotoxins are produced

7) Enteroinvasive Escherichia coli (EIEC)
Characteristics
- Facultative gram-negative rods
- Ferment lactose

Transmission
- Fecal-oral route
- Food-borne route

Pathogenesis
- closely resemble Shigella in their pathogenic mechanisms
- penetrate and multiply within epithelial cells of the colon causing widespread cell destruction
- EIEC are invasive organisms which are same as Shigella but they do not produce LT or ST toxin and, unlike Shigella, they do not produce the shiga toxin

References

1) http://www.wrongdiagnosis.com/ >enterocolitis

2) Levinson, W. (2006). Review Of Medical Microbiology and Immunology. (9th ed.). US: The McGraw-Hill Company.

Soong Ci Liang
0503333G
TG01

MMIC PBL

Particulars of Patient

Name: Ong Fei Fei
Sex: Female
Age: 37

Clinical Diagnosis

Complaints: Fever, pain during urination, virginal discharge
Diagnosis: UTI
Antibiotic Treatment: Nil
Particulars of Specimens
Specimen: Vaginal Discharge

Description of Urinary Tract Infection (UTI)

In healthy people, urine in the bladder is sterile—no bacteria or other infectious organisms are present. The channel that carries urine from the bladder out of the body (urethra) contains no bacteria or too few to cause an infection. However, any part of the urinary tract can become infected; an infection anywhere along the urinary tract is called a urinary tract infection.

UTIs are usually classified as upper or lower according to where they occur along the urinary tract. Lower UTIs are infections of the urethra (urethritis) or bladder (cystitis); upper UTIs are infections of the kidneys (pyelonephritis) or ureters (ureteritis).

Causes

UTIs are almost always caused by bacteria, although some viruses, fungi, and parasites can infect the urinary tract as well. Common organisms that cause UTIs include: Escherichia coli and Staphylococcus saprophyticus. Less common organisms include Proteus mirabilis, Klebsiella pneumoniae, Enterobacter spp, Pseudomonas and Enterococcus spp.

Bacteria: Bacterial infections of the lower urinary tract—the bladder and urethra—are very common. Escherichia coli is the most common bacteria. When the person has a kidney stone, Proteus bacteria may be able to grow. These conditions can lead to abnormal vaginal discharge which can be caused by Chlamydia and Gonorrhea.

Viruses: The herpes simplex virus type 2 (HSV-2) may infect the urethra to cause a UTI, making urination painful and emptying of the bladder difficult.

Fungi: Certain fungi or yeasts can infect the urinary tract to cause a UTI. The most common type is Candida, which causes candidiasis.

Parasites: A number of parasites, including certain types of worms, can infect the urinary tract.

Trichomoniasis, caused by a type of microscopic parasite, is a sexually transmitted disease that can produce a copious greenish yellow, frothy discharge from the vagina in women.


Investigation required

Microscopy, culture of specimen and antibiotic susceptibility should be requested.

Doreen Ng (tg 01)

MMIC PBL Case 1

Subject: MMIC
Case: Case 1 - Khong Fay Seah
Complaints: Fever, chills, dysuria,
Diagnosis: Urinary Tract Infection

Urinary Tract Infection: A urinary tract infection, or UTI, is an infection that can happen anywhere along the urinary tract. The urinary tract includes the bladder, kidneys, ureters and u rethra. [1]

Dysuria: Painful or difficult urination. This includes burning on urination. Dysuria is most commonly due to bacterial infection of the urinary tract causing inflammation of the bladder (cystitis) or kidney (pyelonephritis).
In women, dysuria may also reflect inflammation of the vagina (vaginitis) or vulva (vulvitis). And in men, dysuria may be due to inflammation of the prostate (prostatitis) or the urethra (urethritis) from gonorrhoea or chlamydia. [2]

Possible Pathogens

Possible Microorganisms	Descriptions
Escherichia Coli	Gram-negative bacilli
Klebsiella spp.	Gram-negative bacilli
Streptococcus spp. (GPC)	Gram-positive cocci
Staphylococcus spp. (GPC) Eg. S saprophyticus, Staphylococcus aureus	Gram-positive cocci
Pseudomonas spp.	Gram-positve bacilli
Proteus spp.	Gram-negative bacilli
Candida spp. Eg. Candida albicans	Fungus
Enterococcus faecalis	Gram-positive cocci
Morganella	Gram-negative bacilli
Serratia	Gram-negative bacilli

Investigation Required
Microscopy:
1) Gram stain - Differentiate Gram positive and Gram negative bacteria
2) Wet mount and KOH smear - Demonstration of pseudohyphae for identification of Candida spp.

Culture:
Aerobic culture on Blood plate agar(BAP), Cysteine Lactose Electrolyte Deficient medium (CLED), MacConkey (MAC)agar plate.

Other Tests:
1) Catalase Tests
2) Oxidase Tests
3) Biochemical Tests

Antimicrobial Susceptibility Test:
To determine the treatment

References:
1. MedlinePlus. (2007) Urinary Tract Infection. Retrieved December 02, 2007, from http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm > >urinary tract infection
2. MedicineNet, Inc. (2007) Definition of Dysuria. Retrieved December 02, 2007, from http://www.medterms.com/script/main/art.asp?articlekey=3163
http://www.medterms.com/script/main/hp.asp > dysuria

Boon Ching
Tg01